CPHAC_DSAC Committee Papers 17 November 2017 - 1. PROCEDURAL BUSINESS

Public

Wairarapa, and Capital & Coast District Health Boards Community & Public Health and Disability Support Advisory Committees

17 November 2017

Wairarapa, Hutt Valley and Capital & Coast District Health Boards

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COMMUNITY & PUBLIC HEALTH AND DISABILITY SUPPORT ADVISORY COMMITTEES

Agenda

17 November 2017, 10.00am to 1.00pm CSSB Lecture Room, Ground Floor Clinical & Support Services Building, Blair Street, Masterton

ITEM ACTION PRESENTER MIN TIME PG 1 PROCEDURAL BUSINESS 15 10am 1 1.1 Karakia 1.2 Apologies RECORD 1.3 Continuous Disclosure - Conflict of Interest ACCEPT 3 1.4 Confirmation of Minutes 1 September 2017 APPROVE 7 1.5 Matters Arising NOTE 1.6 Action List NOTE 13 1.7 Dissolution of 3DHB CPHAC/DSAC APPROVE 15 1.8 DSAC Meeting schedule 2018 APPROVE 17 2 DISCUSSION 2.1 Regional Child Oral Health Nicky Smith 19 Kathy Fuge 2.1 (a) Wairarapa Child Oral Health 25 Lynette Field 2.2 Regional Public Health Update Peter Gush 32 2.3 Regional Screening Update Lindsay Wilde 61 3 INFORMATION 3.1 Bowel Cancer Screening Update H Carbonatto 71 3.2 Disability Strategy Implementation First Pauline Boyles 74 Quarter Report 3.3 Masterton Hospital Accessible Journey Review Pauline Boyles 80

ADJOURN LUNCH 12.30PM 4 APPENDICES 4.1 BEE Healthy Equity Data 90 4.2 Caries Free Data – CCDHB 93 4.3 Healthy Ageing Strategy (Ministry of Health) 94 4.4 Strategic Disability Plan Evaluation Framework 170

Wairarapa, Hutt Valley and Capital & Coast District Health Boards

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COMMUNITY & PUBLIC HEALTH AND DISABILITY SUPPORT ADVISORY COMMITTEES Conflicts & Declarations of Interest Register

UPDATED AS AT AUGUST 2017

Name Interest Dame Fran Wilde ∑ Deputy Chair, Capital & Coast District Health Board (includes HAC) Chairperson ∑ Chair, Remuneration Authority ∑ Deputy Chair NZ Transport Agency ∑ Chair Lifelines Group ∑ Director Museum of NZ Te Papa Tongarewa ∑ Member Whitireia-Weltec Council ∑ Director Business Mentors NZ Ltd ∑ Director Frequency Projects Ltd ∑ Chief Crown Negotiator Ngati Mutunga and Moriori Treaty of Waitangi Claims ∑ Chair Wellington Culinary Events Trust ∑ Chair National Military Heritage Trust Mr Andrew Blair ∑ Chair, Southern Partnership Group (appointed jointly by Ministers of Member Finance and Health to provide governance for the redevelopment of Dunedin Hospital) ∑ Member of the Board of Trustees of the Gillies McIndoe Research Institute ∑ Member, Hutt Valley District Health Board Finance, Risk and Audit Committee ∑ Chair, Hutt Valley District Health Board (from 5 December 2016) ∑ Former Member of the Hawkes Bay District Health Board (2013-2016) ∑ Former Chair, Cancer Control (2014-2015) ∑ Former CEO Acurity Health Group Limited ∑ Director, Safer Sleep Ltd ∑ Director, Safer Sleep LLC Ltd ∑ Advisor to the Board, Forte Health Limited, Christchurch ∑ Owner and Director of Andrew Blair Consulting Limited, a Company which from time to time provides governance and advisory services to various businesses and organisations, include those in the health sector ∑ Chair, Capital & Coast District Health Board (from 5 December 2016) (includes HAC) ∑ Chair, Hutt Valley District Health Board Hospital Advisory Committee ∑ Member, 3DHB combined Community and Public Health and Disability Support Advisory Committees Ms Eileen Brown ∑ Member of Capital & Coast District Health Board

Wairarapa, Hutt Valley and Capital & Coast District Health Boards

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Name Interest Member ∑ Board member (until Feb. 2017), Newtown Union Health Service Board ∑ Employee of Council of Trade Unions ∑ Senior Policy Analyst at the Council of Trade Unions (CTU). CTU affiliated members include NZNO, PSA, E tū, ASMS, MERAS and First Union. ∑ God daughter/family friend employed as a solicitor at specialist health law firm, Claro. Ms Sue Kedgley ∑ Member, Capital & Coast District Health Board (includes HAC) Member ∑ Member, Greater Wellington Regional Council ∑ Member, Consumer New Zealand Board ∑ Shareholder in Green Cross Health ∑ Step son works in middle management of Fletcher Steel ∑ Deputy Chair, Consumer New Zealand ∑ Environment spokesperson and Chair of Environment committee, Wellington Regional Council Mr Alan Shirley ∑ Member, Wairarapa District Health Board (includes HAC) Member ∑ Member, Wairarapa, Hutt Valley and CCDHB CPHAC DSAC Committee ∑ General surgeon at Wairarapa Hospital ∑ Wairarapa Community Health Board Member ∑ Wairarapa Community Health Trust Trustee (15 September 2016) Jane Hopkirk ∑ Member, Wairarapa District Health Board Member ∑ Member, Wairarapa, Hutt Valley and CCDHB CPHAC DSAC Committee ∑ Member, Wairarapa Te Kainga Committee ∑ Kaiarahi, Takiri Mai Te Ata, Kokiri Hauora ∑ Member, Occupational Therapy Board of New Zealand (23 February 2016) Kim Smith ∑ Employee of Te Puni Kokiri Member ∑ Trustee for Te Hauora Runanga o Wairarapa ∑ Brother is Chair for Te Hauora Runanga o Wairarapa ∑ Chair, Te Oranga o Te Iwi Kainga ∑ Sister, Member of Parliament Lisa Bridson ∑ Member, Hutt Valley District Health Board (Includes HAC) Member ∑ Member, 3DHB Combined CPHAC DSAC Committee ∑ Hutt City Councillor ∑ Chair, Kete Foodshare Yvette Grace ∑ Member, Hutt Valley District Health Board (includes HAC) Member ∑ Deputy Chair, 3DHB combined Community and Public Health and Disability Support Advisory Committees ∑ Chair, Te Oranga O Te Iwi Kainga Māori Relationship Board to Wairarapa DHB ∑ Trustee, Rangitane Tu Mai Ra Treaty Settlement Trust ∑ Manager, Compass Health Wairarapa ∑ Member, 3DHB Youth SLA (Service Level Alliance) ∑ Member, Te Whiti Ki Te Uru Central Regions Māori Relationship Board

Capital & Coast, Hutt Valley & Wairarapa District Health Boards

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Name Interest ∑ Husband, Family Violence Intervention Coordinator and Child Protection Officer Wairarapa DHB ∑ Husband, Community Council, Compass Health ∑ Husband, Community member of Tihei Wairarapa Alliance Leadership Team ∑ Sister in law, Nurse at Hutt Hospital ∑ Sister in Law, Private Physiotherapist in Upper Hutt ∑ Niece, Nurse at Hutt Hospital Prue Lamason ∑ Member, Hutt Valley District Health Board (Includes HAC) Member ∑ Member, 3DHB combined Community and Public Health and Disability Support Advisory Committees ∑ Deputy Chair, Hutt Mana Charitable Trust ∑ Deputy Chair, Britannia House – residence for the Elderly ∑ Councillor, Greater Wellington Regional Council ∑ Deputy Chair, Greater Wellington Regional Council Holdings Company ∑ Trustee, She Trust ∑ Daughter is a Lead Maternity Carer in the Hutt John Terris ∑ Member, Hutt Valley District Health Board Member ∑ Member, Hutt Valley District Health Board Hospital Advisory Committee ∑ Member, 3DHB combined Community and Public Health and Disability Support Advisory Committees Mr Derek Milne ∑ Member, Wairarapa District Health Board Member ∑ Member, WrDHB CPHAC/DSAC (30 March 2016) ∑ Brother-in-law is on the Board of Health Care Ltd ∑ Daughter, GP in Manurewa, Auckland Fa’amatuainu Tino Pereira ∑ Managing Director Niu Vision Group Ltd (NVG) Member ∑ Chair 3DHB Sub-Regional Pacific Strategic Health Group (SPSHG) ∑ Chair Pacific Business Trust ∑ Chair Pacific Advisory Group (PAG) MSD ∑ Chair Central Pacific Group (CPC) ∑ Chair, Pasefika Healthy Home Trust ∑ Establishment Chair Council of Pacific Collectives ∑ Chair, Pacific Panel for Vulnerable Children ∑ Member, 3DHB CPHAC/DSAC Dr Tristram Ingham ∑ Senior Research Fellow, University of Otago Wellington Member ∑ Member, Capital & Coast DHB Māori Partnership Board ∑ Clinical Scientific Advisor & Chair Scientific Advisory Board – Asthma Foundation of NZ ∑ Trustee, Wellhealth Trust PHO ∑ Councillor at Large – National Council of the Muscular Dystrophy Association ∑ Trustee, Neuromuscular Research Foundation Trust ∑ Member, Wellington City Council Accessibility Advisory Group ∑ Member, 3DHB Sub-Regional Disability Advisory Group

Capital & Coast, Hutt Valley & Wairarapa District Health Boards

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Name Interest ∑ Professional Member – Royal Society of New Zealand ∑ Member, Institute of Directors ∑ Member, Health Research Council College of Experts ∑ Member, European Respiratory Society ∑ Member, Te Ohu Rata o Aotearoa (Māori Medical Practitioners Association) ∑ Director, Miramar Enterprises Limited (Property Investment Company) ∑ Daughter, Employee of Hutt Valley based Māori provider (Tu Kotahi Māori Asthma Trust) ∑ Wife, Research Fellow, University of Otago Wellington Sue Driver ∑ Member of Capital & Coast District Health Board (Including HAC) Member ∑ Member, 3DHB combined Community and Public Health and Disability Support Advisory Committees ∑ Community representative, Australian and NZ College of Anaesthetists ∑ Board Member of Kaibosh ∑ Daughter, Policy Advisor, College of Physicians ∑ Former Chair, Robinson Seismic (base isolators, Wgtn Hospital) ∑ Advisor to various NGOs ‘Ana Coffey ∑ Member of Capital & Coast District Health Board (Including HAC) Member ∑ Member, 3DHB combined Community and Public Health and Disability Support Advisory Committees ∑ Councillor, Porirua City Council ∑ Director, Dunstan Lake District Limited ∑ Trustee, Whitireia Foundation

Capital & Coast, Hutt Valley & Wairarapa District Health Boards

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3DHB CPHAC/DSAC Meeting

DATE: 1 September 2017 TIME: 9am - Midday

VENUE: Boardroom, Pilmuir House, Hutt Valley District Health Board

PRESENT: Dame Fran Wilde (Chair), Bob Francis, Derek Milne, Dr Tristram Ingram, Lisa Bridson, Prue Lamason, Ana Coffey, Yvette Grace, Sue Kedgley, Andrew Blair (from 11.30am),

APOLOGIES: Alan Shirley, Tino Pereira, John Terris, Jane Hopkirk, Kim Smith, Sue Driver,

IN ATTENDANCE: Debbie Chin, Ashley Bloomfield, Adri Isbister, Rachel Haggerty, Helene Carbonatto, Nigel Broom, Pauline Boyles, Jenny Langton (minutes)

PUBLIC No members of public present Advance Care Planning: PRESENTERS Catherine Epps, Director Allied Health, CCDHB Helen Rigby, Project Manager, Strategy Innovation and Performance, CCDHB

Aged Care Services update: Jan Marment, Senior System Development Manager – Older People, CCDHB Kate Calvert, Portfolio Manager – Older People, HVHDHB Joanne Edwards, Portfolio Manager – Older People, Wairarapa DHB

Agenda Item Discussion Action Required And by Whom

1 PROCEDURAL BUSINESS

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1.1 KARAKIA Tristram Ingram led Karakia, Committee Chair, Dame Fran Wilde, welcomed members and DHB staff

1.2 APOLOGIES Received from Jane Hopkirk, Eileen Brown, Sue Driver

1.3 INTEREST REGISTER No new conflicts

1.4 Confirmation of previous Correction noted – both Ana and Yvette were present at the last minutes meeting. Derek noted the previous request for a short overview of mental health system hasn’t been minuted. Staff noted that the request was picked up as an action and is included on the action list to provide in 2018. Otherwise, minutes were accepted as true and correct. Derek Milne

1.5 Matters arising No matters arising

1.6 Action points Note action point 2.1 – Mental Health and Wellbeing is linked to the minuted request for short overview of the health system (see 1.4 above)

1.7 Final CPHAC/DSAC Terms of The combined terms of reference were noted. Reference

2 DISCUSSION

2.1 Palliative Care Strategy paper The difference in approaches across the three DHBs was NOTED. This is partly due to different hospice settings in each of the DHBs. The Gold Standards Framework for Palliative Care was identified as a tool that the DHB should have regard to.

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A consumer voice in palliative care discussions was NOTED as important. Consumer Council probably needs older person’s representation. The Committee ENDORSED the progress of the 3 DHBs against the sub-regional Palliative Care Strategy

2.2 Advance Care Planning Presentation outlining progress with implementing Advance Care presentation Planning (ACP) across the sub-region in all settings. Helen Rigby Stimulated broad discussion about the importance of these conversations and what is needed to enable this to happen. ACP Catherine Epps represents a social movement and we need to ensure there are no system or workforce barriers to the conversation happening. Concern was raised that we don’t create unintended consequences (eg, is there a risk of bias to conversations being had with people deemed ‘less worthy’ of being kept alive). Members NOTED generally Māori do not find it difficult to talk about death and observed a more likely explanation for not reaching Māori is clinician discomfort. The key is the way you have the conversation and that different approaches are needed for Māori whānau (it is less about the document/piece of paper). Staff are starting the conversation about ACP with Pasifika communities also. Pamphlets in six pacific languages have been developed. The Committee RECOMMENDED the ACP presentation be given to the Pacific Sub-Regional group. Staff described the Northland DHB “waka” model for ACP that they would be bringing Northland down to present to the sub-region. Derek MOVED that the Pacific sub-regional group be invited to attend when Northland come to present the Waka model.

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2.3 Aged Care Services Update Presentation followed by discussion on Aged Care Services and quality assurance of ARC providers. Jan Marment Discussed the need for a life-course approach in planning and Kate Calvert commissioning services. A comment that the current hard lower Joanne Edwards age-limit (65) is restrictive – ideally there would be a softer age limit for access to aged care services. Staff noted current funding models limit flexibility in this area. Noted there are national and local roles and responsibilities across the whole social system and the action plan to implement the new Health Ageing strategy is important. ACTION: Distribute the Healthy Ageing action plan with the minutes. Discussed the role of DHB Boards in monitoring quality standards in ARC and the associated challenges given Boards don’t directly commission or deliver the services. Boards would like to see some form of regular dashboard looking at ARC provider performance. ACTION: The three GMs will look at what information we have ready access to that could sensibly be reported to Boards on a regular basis.

3 DISCUSSION

3.1 Sub-regional Disability Update Updated on implementation of the 3DHB Disability Strategy Bob Francis Good progress being made working with Ministry of Health, Health and Disability Commissioner and 3DHB ICT on developing an Pauline Boyles electronic Health Passport. We are looking at a platform that is owned by the person, easy to operate an interoperable with other health IT systems. Working to develop a reporting Dashboard by the end of this Year.

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Discussed the current complexities in NASC services particularly the challenges transitioning to different services (eg child transitioning to adult etc). Members consider we need to work towards a single NASC locally irrespective of national progress. Staff noted a project is underway to move towards a single whole of life NASC for the sub-region and would be happy to provide an update of this work, which is proving more complex than it sounds. The Committee suggested there should be regular reports on this issue to DSAC. Recommendations in the paper were accepted.

4.0 OTHER

4.1 Structure of CPHAC-DSAC across Paper recommended maintaining a sub-regional DSAC for services the sub-region that are delivered within a 3DHB model – ie, disability support services and mental health. Paper recommended respective Boards manage CPHAC locally within individual DHBs to allow stronger focus on local population health needs including health equity for local prioritisation of health strategies and investment. Wide ranging discussion about the challenges with servicing a 3DHB Committee since SIDU was disestablished and the limited ability for the Committee to influence the direction and outcomes of initiatives across three DHBs. However, there was concern about losing 3DHB forum to guide opportunities for collaboration, collective activity and strengthened integration where appropriate. There was widespread agreement that there needs to be an on-going focus on sub-regional approaches and integration where possible.

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Staff noted the three DHBs are working collectively across a range of initiatives outside of the CPHAC-DSAC process and considered there are a range of formal and informal opportunities for collaboration. The Committee ENDORSED the recommendations Fran Wilde/Derek Milne The Committee also RECOMMENDED the three Chief Executives consider how strategic integration across the sub-region can be advanced at a governance level should the respective Boards agree to move to local CPHAC structures.

NEXT MEETING 17 November 2017

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SCHEDULE OF ACTION POINTS - PUBLIC CPHAC-DSAC COMMITTEES

AP No: Topic: Action: Responsible: How Dealt With: Delivery Date: Ex CPHAC-DSAC Public Meeting 20 November 2015 1.3 Confirmation of Equity indicators will be reviewed annually. Director, SIP On June 2017 agenda. Closed Minutes

Ex CPHAC-DSAC Public Meeting 20 May 2016 2.3 Equity Monitoring Requested management to bring back to the Director, SIP Replaced by development of November, 2017 Indicators Committee in the next Equity Report an outline of Equity Approach presented at the specific actions in the Annual Plan and the March 2017 meeting. Maori Health Plan and advice to the Committee so Recommendations to come back it could advise the Boards on an equity action plan to November 2017 meeting over a longer time period.

2.5 Regional Public Report back on DHBs role in working with the HVDHB On work programme for November, 2017 Health Update Report homeless as they often have high health needs and November 2017. find access to services difficult. Ex CPHAC-DSAC Public Meeting 6 June 2017 2.1 Mental Health and Equity and co-design needs to be explicitly stated Director, SIP Regular updates provided to First 2018 Wellbeing in recommendations: CPHAC/DSAC meetings. Whole meeting. System Investment Plan early 2018. Ex CPHAC-DSAC Public Meeting 1 September 2017 2.1 Advanced Care Requested that the Pacific sub-regional group be Director, SIP Planning invited to attend when Northland come to present the Waka model. 2.3 Aged Care Services ACTION: The three GMs will look at what Update information we have ready access to that could sensibly be reported to Boards on a regular basis.

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4.1 Structure of CPHAC- Recommended the three Chief Executives consider DSAC across the sub- how strategic integration across the sub-region can region be advanced at a governance level should the respective Boards agree to move to local CPHAC structures.

ITEMS CLOSED SINCE LAST MEETING – 1 September 2017 AP No: Topic: Action: Responsible: How Dealt With: Delivery Date: Ex CPHAC-DSAC Public Meeting 6 June 2017 1.7 Final CPHAC/DSAC Amend and correct grammatical errors. Reflect Secretariat Secretariat to make changes, Closed Terms of Reference 3DHB representation and clarify if there is a clarify query and send out to process for proxies in the absence of members members. particularly from sub regional group and Maori Partnership Board 3.2 Quality Assurance – Ensure the appropriate discussion on quality Director, SIP Discussion at September 2017, Closed Health of Older assurance in Health of Older People. CPHAC/DSAC. People 3.3 Update Bowel screening rolling out at Hutt Valley and CE, HVDHB Update on bowel screening to September, 2017 Wairarapa DHB. CPHAC/DSAC. These services are implementing in short timeframes. The update for CPHAC DSAC has been delayed till September 2017.

Ex CPHAC-DSAC Public Meeting 1 September 2017 2.3 Aged Care Services ACTION: Distribute the Healthy Ageing action plan Director, SIP Distributed with Agenda Closed Update with the minutes.

Wairarapa, Hutt Valley and Capital & Coast District Health Boards 2

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PUBLIC

DISCUSSION PAPER

13 November 2017

Author Rachel Haggerty, Director, Strategy, Innovation and Performance

From: Rachel Haggerty, Director Strategy Innovation and Performance

Endorsed By Debbie Chin: Chief Executive Capital and Coast DHB Ashley Bloomfield, Chief Executive, Hutt Valley DHB Adri Isbister: Chief Executive, Wairarapa DHB

Subject 3DHB Disability Services Advisory Committee

It is recommended that CPHAC DSAC members: ß note the DSAC meeting schedule for 2018 ß note the proposed membership remains as current, to be confirmed by each Board ß note the Terms of Reference for the DSAC will be presented to the first meeting in March 2018

1. PURPOSE At the 3DHB CPHAC DSAC it was agreed that: a. DSAC is maintained at a sub-regional level, meeting quarterly, and focus on those areas managed and delivered across the sub-region being mental health and disability support services. b. CPHAC is managed locally at an individual DHB level enabling a focus on the needs of local populations including equity, enabling prioritisation of localised health strategies and investment requirements. This paper briefly outlines the approach for 2018, the membership and the meeting schedule.

2. DISCUSSION In summary the purpose of DSAC is to consider the needs of the population, the services provided and the plans and opportunities to improve outcomes as they relate to supporting those with disability and those with mental illness and addiction. These two service areas are planned and led across the 3DHBs. The Terms of Reference will be presented to the March meeting. Mental health and disability are, of course, connected to community, public health, primary care and specialty services planning and funding. By having a 3DHB focus it provides greater time to consider the issues and opportunities and develop stronger Board understanding in these important areas. This will strengthen the leadership opportunities for change. These inter-connections between the areas of focus will be managed through the relationship between DSAC and the Boards and CPHACs of each DHB.

Wairarapa, Hutt Valley and Capital & Coast District Health Board

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PUBLIC 3. MEMBERSHIP The initial membership from CPHAC DSAC has been transferred to DSAC. This membership is: CCDHB HVDHB WDHB Invited Fran Wilde Chair Lisa Bridson Jane Hopkirk Bob Francis (SRDAG) Andrew Blair (CCDHB & Yvette Grace Deputy Derek Milne Dr Tristram Ingham HVDHB) Chair Alan Shirley (MPB) Eileen Brown Prue Lamason Kim Smith Tino Pereira (SRSHAG) Ana Coffey John Terris Sue Driver Sue Kedgley

4. MEETING SCHEDULES In planning the meeting schedules quarterly meetings have been identified as needed particularly considering the focus of the new Government on Mental Health and Addictions. The proposed dates are below. ∑ Monday 19 March ∑ Monday 18 June ∑ Monday September 10 ∑ Monday December 3

Wairarapa, Hutt Valley and Capital & Coast District Health Board

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CAPITAL & COAST DISTRICT HEALTH BOARD

3District Health Board – Disability Services Advisory Committee

Meeting duration 10.00am–12.30pm

Time Date Location Members

10am Monday 19 Fran Wilde (CCDHB) Chair March Andrew Blair (HVDHB) Lisa Bridson (HVDHB) 10am Monday 27 Eileen Brown (CCDHB) August Yvette Grace (HVDHB) Deputy Chair Sue Kedgley (CCDHB) Prue Lamason (HVDHB) Derek Milne (WDHB) Jane Hopkirk (WDHB) Alan Shirley (WDHB) Kim Smith (WDHB) John Terris (HVDHB) Sue Driver (CCDHB) ‘Ana Coffey (CCDHB) Bob Francis (SRDAG) Tino Pereira (SRSHAG) Dr Tristram Ingham (MPB)

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Capital & Coast District Health Board – Community and Public Health Advisory Committee

Meeting duration 9.30am–12.00pm

Time Date Location Members

9.30am Monday 12 Fran Wilde (CCDHB) Chair February Eileen Brown (CCDHB) Sue Kedgley (CCDHB) 9.30am Monday 16 Sue Driver (CCDHB) April ‘Ana Coffey (CCDHB) Bob Francis (SRDAG) 9.30am Monday 11 Tino Pereira (SRSHAG) June Dr Tristram Ingham (MPB) 9.30am Monday 24 September

9.30am Monday 19 November

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PUBLIC

CPHAC/ DSAC INFORMATION PAPER

Date: 27 October 2017

Author Nicky Smith, Service Manager, Regional Child Oral Health Service Kathy Fuge, Clinical Director, Regional Child Oral Health Service

Endorsed By Dale Oliff, Chief Operating Officer, HVDHB

Subject Regional Child Oral Health Service Update

RECOMMENDATION

It is recommended that CPHAC/DSAC: a. NOTE that all Regional Dental Hubs are fully operational, with over 73,000 children enrolled in the service (Hutt Valley DHB and CCDHB); b. NOTE that mobile vans access most schools in the region to provide on-site dental examinations for primary and intermediate school aged children; c. NOTE that the Service accommodates the needs of children with disabilities and works closely with secondary dental services to ensure wrap-around provision of care for these children; d. NOTE there is a number of equity initiatives underway, including clinical best practice initiatives, to improve service responsiveness to Maori and Pacific children in order to reduce arrears and increase attendance at follow-up treatment appointments; e. NOTE that the service is being reviewed this year now that the new model of care is fully implemented to ensure it is sustainable and able to deliver to the needs of the population in future.

ADDENDUMS:

SERVICE BALANCED SCORECARDS SEPTEMBER 2017

HVDHB AND CCDHB DMFT 2016

1 PURPOSE

This paper updates CPHAC/ DSAC on the work of the Regional Child Oral Health Service.

2 WELLINGTON REGIONAL CHILD ORAL HEALTH SERVICE (RCOHS)

2.1 Background Hutt Valley DHB is the current Ministry of Health (MoH) contract holder for the Regional Child Oral Health Service, which encompasses the CCDHB and the Hutt Valley DHB regions. Service delivery is via 13 fixed dental hub clinics and 11 examination mobile vans.

Hutt Valley District Health Board

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PUBLIC 2.2 Enrolment Children born in the region are enrolled at birth (since 2015), with a first examination scheduled at two years of age. We have currently over 73,000 children enrolled in the RCOHS, aged 0-13.

2.3.1 Current Model The Service provides free dental care for children up to the age of 18 (under MoH service specifications). Care for children from birth to school-year-8 is provided directly by clinicians employed by the service. During Year 8, children are transferred to a private dentist of their choosing, which is funded until they are 18 via the Combined Dental Agreement (CDA). The service is responsible for transferring children at year 8 to a nominated private provider with a contract.

The Service operates under a shared care model in which all children in the region are allocated to a dental hub, which is then responsible for ensuring that the children are recalled for examination annually and that treatment identified is undertaken promptly. Pre-school aged children are routinely called for their first examination to one of the thirteen regional dental hubs at the age of two. Pre- school-aged children are then offered routine annual examinations in a hub setting. Complementary approaches are used to reach Maori and Pacific children, particularly targeting low decile Te Kohanga Reo and Early Childhood Centres (ECC) and to provide ‘knee-to-knee’ dental examinations for enrolled children.

When enrolled in a primary school, these children are then identified on the school rolls and examined on an annual basis. Mobile dental vans parked in school grounds provide examinations, preventive treatment and x-rays (if required). This model supports high levels of equitable participation for children enrolled in these schools, with every child receiving a dental examination and preventative treatment in school hours. The region has 29 ‘no access’ schools (due to topography and space) and children attending a no-access school are seen by appointment in their assigned dental hub with their parent/ caregiver. All dental treatments are undertaken at a dental hub.

2.3.2 Children with Disabilities Children with disabilities are seen wherever best suits their particular needs. Some children prefer to attend the mobile with their class mates. Some caregivers prefer to bring children in by appointment. All hubs except Paraparaumu, , and upstairs at Selby House have wheelchair access. Children with complex medical or management needs are referred to the hospital dental departments where they receive one complete treatment then return to the RCOHS or have on going regular care in the hospital department. For example; children undergoing active treatment for cancer receive all care in the hospital department until 12 months after the completion of their active cancer treatment. Children who require extensive treatment may receive this care in the hospital, then return to the community oral health service for routine examinations and prevention. We have an ongoing relationship with CCDHB where a Registered Nurse and one of our therapists visit Mahinawa Specialist School (in Porirua) and its satellite classes for yearly examinations and care (when required) is provided at most appropriate location for child.

2.4 Workforce The RCOHS currently employs 34.78FTE Registered Dental Therapists and 34.81FTE Dental Assistants to provide dental care to enrolled children. The Dental Hub teams are supported by a Service Manager, 3 Team Leaders, a Clinical Director (0.7 FTE), 2 Community Dentists (0.8 FTE), an Early Intervention Prevention Team and an administrative team. RCOHS has approval to recruit eight new Graduates for 2018 and is currently planning this with Otago University and AUT.

Hutt Valley District Health Board

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PUBLIC

Workforce succession planning and growing the workforce has commenced with Career and Allied Health Salary Progression Framework being supported. Dental Therapists will have the opportunity to undertake CASP Step 7 during 2018, supported by RCOHS Leadership Team and the HVDHB Director of Allied Health. In addition, the leadership team is currently drafting a CASP Maintenance Programme for staff who have achieved CASP (step 7), to ensure that they are supported and challenged to innovate and grow the Service appropriately.

2.5 Early Intervention and Prevention Team The RCOHS Early Intervention and Prevention Team work alongside clinical staff to provide health promotion support and facilitate pre-school examinations in 61 Kohanga Reo and Early Childhood Centres in the Region. This team is also responsible for the year 8 adolescent transfer process (to private dentists with a combined dental agreement contract).

3 SERVICE DELIVERY MEASURES

The service publishes a monthly scorecard with key service delivery indicators for staff and some external stakeholders to follow progress throughout the year. The October scorecard is appended.

The service reports four data sets annually (20 April) to the Ministry of Health for the previous calendar year; these reports are provided in the appendix: ∑ PP10 is the number of decayed missing and filled permanent teeth (DMFT) and % caries free for enrolled year 8 children ∑ PP11 is the decayed, missing and filled deciduous (baby) teeth (dmft) and % caries free for enrolled 5 year olds. % Caries free is a measure of caries prevalence ( i.e. how much is out there in the population); a higher value is good. DMFT/dmft is a measure of caries severity (i.e. how severe is that experience for individuals and populations); a lower value is good. ∑ PP12 is a measure of adolescent utilisation of publicly funded services that is populated by the MoH from pro-claim data. Extra volumes can be added by each DHB. ∑ PP13a is the % of preschool children enrolled in the service based on a population denominator from Statistics NZ. PP13b is the % of enrolled children who did not receive their annual examination (arrears). Both these are influenced by a combination of families not attending an examination booked (Did not attend) and children not being offered an appointment due to service constraints; there are specific initiatives in train to address both of these factors.

The level of caries in a population is largely influenced by socio-demographic determinants, water fluoridation, oral health practices and diet including beverage choices so are likely to fluctuate slightly year-on-year but remain reasonably constant until population-based and targeted upstream changes are instigated that reduce poverty, sustain equity and enable and effect healthy lifestyle choices.

4 UPDATE OF CURRENT WORK PLAN AND PLANNING FOR 2018

4.1 Equity of Service Initiatives

4.1.1 Hub Administration Roles A number of initiatives have recently been instigated to target children who are either in arrears or have not attended appointments, the highest being Maori and Pacific children. These include the introduction of Hub Administration Support Roles to exclusively target these children. The three roles

Hutt Valley District Health Board

21 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

PUBLIC are placed in each of the three large hubs of (Hutt Team), Brandon (Kapi-Mana team) and Selby House (Wellington Team) and are responsible for administration support for the hubs that come under each team.

4.1.2 Holiday Programme RCOHS has been working in conjunction with Ora Toa and Porirua City Council for the funding and installation of mobile van plugs in areas where there can be targeted school holiday programmes for provision of dental examinations. To date, the team has provided mobile dental examinations during the Easter and July school holidays at Ora Toa (Cannons Creek) and have just completed a successful week at Te Rauparaha Arena in which 71 children were examined in 4 days, a large percentage of which were local pre-school aged children. The RCOHS is currently in discussion with Wellington City Council for funding mobile sites and has plans to increase the number of plugs in targeted areas in Upper and through working with the respective Councils during 2018.

4.1.3 Increasing scope for Early Intervention and Prevention Team (EIP) The EIP Team is currently working in conjunction with Maori and Pacific providers for the 2018 programme to be present for health promotion events in our communities, e.g. Creekfest and PolyFest.

In addition, the team is widening its scope for Te Kohanga Reo ECC and Kindergarten visits for 2018, which has shown to be successful at providing dental examinations for pre-school aged children, through knee-to-knee checks. Planning is currently in progress for this initiative.

The EIP are also working with Regional Public Health (RPH) and Healthy Families to provide support for the ‘Water in Schools’ initiative. From 2018, the RCOHS will provide each school (post dental van visit) with data on children seen and the percentage of caries identified in those children with the option for the school to be contacted by RPH for further discussion in this initiative.

4.1.4 Late Night Appointment Trials The Service has been trialling late night appointments at Naenae Dental hub from Term 3, in order to provide increased flexibility of dental appointments for children. To support this initiative, processes have been developed to support staff treating children at these appointments. Evaluation and feedback is due January 2018, with potential to roll this out across the Service in targeted areas.

4.1.5 Consumer Feedback In order to better understand and be more responsive to the needs of our children and their caregivers, the RCOHS is currently trialling an electronic consumer feedback survey in Term 3 and Term 4 in all dental hubs. The effectiveness of this survey including feedback is closely monitored and will be evaluated in January 2018 to assess its effectiveness.

5 CLINICAL BEST PRACTICE

Clinical best practice for the individual child is dependant upon a comprehensive caries risk assessment at the outset of their care. This may change at each subsequent examination. Clinical care is tailored to the needs and abilities of the individual child to cope. If a child has care that is out of the scope of a therapist or has extensive needs making care difficult in the clinic setting, they are referred to a contracted private dentist or to a DHB hospital department for a first specialist assessment (FSA) to consider sedation or general anaesthetic to help manage their care.

Hutt Valley District Health Board

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PUBLIC 5.1 Radiographs Diagnostic posterior bitewing x-rays should be taken on children as soon as the spaces between teeth have closed and surfaces can not be seen visually any more (around 4-5 years) and then according to risk (high risk: 6-12 monthly; low risk: 2 yearly). Our therapists have undertaken this since 2012 across the service and are audited yearly.

5.2 Preventative Treatment (Fluoride varnish) Fluoride Varnish is a high fluoride treatment that is applied to children’s teeth according to risk. It provides further decay prevention even in the presence of good tooth brushing practices and water fluoridation. Children at high risk of caries need twice yearly application, while low risk children in a fluoridated area required it once a year or not at all. The therapists are audited regularly on the use of this preventive tool.

5.3 Stainless steel crowns (SSC) SSC are a silver metal cover that is placed over a tooth rather than using a white or silver filling. They have a better success rate and are more likely to last the lifetime of a baby tooth meaning a chid will only need to have a filling done once and not replaced. They are the gold standard for back baby teeth with medium to large sized cavities. Conventional SSCs involved the removal of the decayed tooth tissue. A novel method called the Hall Technique is now being introduced to the service that has strong national and international evidence for its longevity, safety and child acceptability where the decay is not removed but the crown simply cemented over the tooth. The decay stops growing and the tooth lasts in-situ until it exfoliates naturally between 10-12 years of age. Introduction of this technique to our service is exciting as it adds another tool to the therapist armamentarium which may mean the child has a quick treatment with no need for injection or drilling. Often this means that a child unable to cope with conventional treatment can receive this as an alternative and not need a referral to hospital for treatment under GA. The main reason a caregiver or child would decline this option is the silver colour but this is becoming more widely accepted.

Approximately half our therapists have the scope to provide SSC and pulpotomy (a deciduous root canal treatment). We have recently gained accreditation to provide training for therapists to add this to their scope of practice. Our first four therapists without the scope will receive this training early November 2017 with a plan to train the remaining therapists both here and in the Wairarapa in the next 12 months so that all therapists can offer the same treatment options consistently according to evidence based best practice.

6 ADDITIONAL PLANNING FOR 2018-2020

This year has largely been centred on fully establishing the new model of care and allowing the new full time service manager to clarify and consolidate and allocate budget and service delivery. This has put us in a better position to plan for a strong future. Our future vision is based on having the child at the centre, and consistently delivering evidence-based changes that allow children to live play and learn free of pain and decay from their teeth. We are working towards a service team that are supported to provide high quality targeted care and prevention in a timely manner.

6.1 Digital Radiography The RCOHS is developing a project plan for the implementation of digital radiography, which allows diagnosis at point of examination, with immediate formulation of treatment plan (this is unavailable to RCOHS currently).

Hutt Valley District Health Board

23 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

PUBLIC 6.2 Mobile Van Resources A business case for an additional mobile dental van is being developed as the current mobile vans are at full capacity, which this prohibits the Service from increasing the number of children who are able to have onsite dental examinations whilst at school. An additional mobile dental van would allow a greater number of children to be examined at school and would also allow coverage for periods when existing mobile dental vans are off the road for maintenance and repair.

Hutt Valley District Health Board

24 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

CPHAC-DSAC INFORMATION PAPER

Date: 7 November 2017

Lynnette Field, Clinical team leader, Wairarapa Oral Health Service Author

Endorsed by Nigel Broom, Wairarapa DHB Oral Health Service update Subject RECOMMENDATION It is recommended that CPHAC-DSAC: 1. NOTE that both mobiles and the community Dental Clinic are fully operational. 2. NOTE that Wairarapa have an annual rotation of 15 locations with the mobiles and that Wairarapa DHB ensures that each town has at multiple visits per year aside from Tinui, Martinborough and Kahutara who only have one. 3. NOTE that Lakeview which has been identified as having the most ‘at risk’ children receives 4 visits per year (one each term) 4. NOTE that we work closely with the mobile surgical bus service to provide GA services to the children in the Wairarapa. 5. NOTE that we work closely with HVH and CCH to ensure those with special needs have access to tertiary services. 6. NOTE that we are awaiting the outcome of the ministry of health information technology review when a national oral health computer programme will be settled on. This will act as a catalyst for the introduction of this programme to the Wairarapa oral health service.

Appendices:

1. Wairarapa DMFT 2016 2. Achievements against workplan

1. PURPOSE The purpose of this report is to update CPHAC/DSAC on the work of the Wairarapa Oral Health Service.

2. BACKGROUND Wairarapa District Health Board is the current Ministry of Health (MoH) contract holder for the Oral Health service that encompasses the Wairarapa. The service is delivered from the Community Dental Clinic and two, 2 chair mobiles which travel around the Wairarapa providing the same full service as the Community Dental Clinic.

2.1 Enrolments

Children in the region are enrolled at birth and the family is first seen when the baby is around 10 weeks old. At the end of 2016 we had a roll of 7152 children from birth till the end of year 8.

2.1.1 Current Model The service provides free dental care for children up to the age of 18 (under MoH service specifications). As previously stated care is provided up until the end of year 8 by the personnel of the Wairarapa oral health service and after that the students are transferred to a private dentist. All dentists within the Wairarapa are party to the

25 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

Combined Dental Agreement so parents can choose whichever dentist best meets their needs. The service employs an adolescent oral health coordinator who works with the staff of the oral health service to ensure all students are transferred to a private practitioner.

The service operates as a team and all children within the Wairarapa District Health Board are able to be seen at either the community dental clinic or the mobiles when in their area. Pre-school children are seen at 10 weeks (approximately) and then annually thereafter. Schools notify us when children enroll and they are added to the roll of that school. An annual check is done to ensure all children in educational settings are on our books.

Mobiles parked within schools provide the same care for the children of the school as the community dental clinic. This includes prevention, radiographs and treatment.

2.1.2 Children with special needs

Children with disabilities or special needs are seen wherever best suits the family. This can include home visits for those who are acutely ill and where the family is asking for advice. Children with complex management needs can be seen on either the mobile surgical bus or if there is medical issues as well they may be referred to either Hutt or Capital Coast hospitals according to their needs.

2.2 Workforce We currently employ 6FTE registered Dental Therapists and 3FTE dental assistants. We have .9 Administration support and .5 Clinical team leader to provide dental care for 7152 children. We have had approved an increase of .4 FTE Dental Therapist and we will be appointing a new graduate who will use this FTE along with .6 from a retiring Dental Therapist. We are currently interviewing Otago university 2018 graduates. We have an aging workforce but with the retirement of one therapist and the imminent retirement of yet another we are working at ensuring a healthier age spread amongst staff.

2.3 Service Delivery measures. The service reports annually (20th April) to the ministry. These reports are attached in the appendices.

The level of caries in a population is largely influenced by socio-demographic determinants, water fluoridation, oral health practices and diet including beverage choices so the level of caries fluctuates annually.

The Wairarapa has a particular issue in that our highest needs groups are within our fluoridated areas.

3. UPDATE ON CURRENT WORK PLAN AND PLANNING FOR 2018

3.1 Increase in scope of practice for dental therapists We are currently working towards adding stainless steel crowns to the scope of every dental therapist within the Wairarapa DHB along with pulpotomies.

3.2 New Graduate 2018 will see us with a new graduate. A great deal of mentoring and support will be offered to this person. We will only have 5 FTE therapists to do this so one person will be taken out of the operating equation for the first term. This will cause a stress to the service in the short term but the long term gain is a fully functional therapist to add to our team.

3.3 iMoko The Wairarapa DHB has a trial introduction of a programme called iMoko. This programme provides immediate medical care for an enrolled group of children. Oral health will be an integral part of this service providing training on oral health issues to the adults referring the children and assisting when necessary.

26 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

3.4 Wahi Pai Wahi Ora The two Maori health providers within the Wairarapa are running a programme to assist Maori with various oral health needs to access services. The oral health service provides professional advice and is part of the steering committee as well as providing training in the needs for a healthy mouth for the participants.

4. CLINICAL BEST PRACTICE Clinical best practice for the individual child is dependent upon a comprehensive caries risk assessment at the outset of their care. This may change at each subsequent examination. Clinical care is tailored to the needs and abilities of the individual child to cope. If a child has care that is out of the scope of a therapist or has extensive needs making care difficult in the clinic setting, they are referred to a contracted private dentist or to the outpatients dept. for a first specialist assessment (FSA) with the dentist who operates on the Mobile Surgical Bus to consider general anesthetic to help manage their care.

4.1 Radiographs Diagnostic posterior bitewing x-rays should be taken on children as soon as the spaces between teeth have closed and surfaces can not be seen visually any more (around 4-5 years) and then according to risk (high risk: 6-12 monthly; low risk: 2 yearly). Our therapists have engaged this best practice since 2012

4.2 Preventative Treatment (Fluoride varnish) Fluoride Varnish is a high fluoride treatment that is applied to children’s teeth according to risk. It provides further decay prevention even in the presence of good tooth brushing practices and water fluoridation. Children at high risk of caries need twice yearly application. Low risk in a fluoridated area once a year or not at all.

4.3 Stainless steel crowns (SSC) SSC are a silver metal cover that is placed over a tooth rather than using a white or silver filling. They have a better success rate and are more likely to last the lifetime of a baby tooth meaning a child will only need to have a filling done once and not replaced. They are the gold standard for back baby teeth with medium to large sized cavities. Conventional SSCs involve the removal of the decayed tooth tissue. A novel method called the Hall Technique is now being introduced to the service that has strong national and international evidence for its longevity, safety and child acceptability where the decay is not removed but the crown simply cemented over the tooth. The decay stops growing and the tooth lasts in-situ until it exfoliates naturally between 10-12 years of age. Introduction of this technique to our service is exciting as it adds another tool to the therapist armamentarium which may mean the child has a quick treatment with no need for injection or drilling. Often this means that a child unable to cope with conventional treatment can receive this as an alternative and not need a referral to the mobile surgical bus for treatment under GA. The main reason a caregiver or child would decline this option is the silver colour but this is becoming more widely accepted.

We are still undergoing training in this scope and expect to introduce this next year. (2018)

Pulpotomy (a deciduous root canal treatment) is also a scope we will introduce in 2018. Hutt Valley DHB has gained accreditation to train in these two scopes and they plan to train the therapists both there and in the Wairarapa in the next 12 months so that all therapists can offer the same treatment options consistently according to evidence based best practice.

27 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

APPENDIX 1:

Wairarapa DMFT Scores for 2016 – Year 8 Children

Calendar year 2016 Number of Number of Decayed, Mean DMFT for children with caries Number of Number of Number of Teeth Number of Missing due Children Children % Caries Free Mean D Mean M Mean F Mean DMFT Decayed Teeth Missing due Filled Teeth to caries Examined Caries-Free to Caries and Filled Mean Dental Health Status Teeth Mean D Mean M Mean F DMFT All Year 8 Children 378 243 8 0 278 286 64% 0.02 0.00 0.74 0.76 0.06 0.00 2.06 2.12 All Maori Year 8 Children 83 46 8 0 84 92 55% 0.10 0.00 1.01 1.11 0.22 0.00 2.27 2.49 All Pacific Year 8 Children 11 7 0 0 8 8 64% 0.00 0.00 0.73 0.73 0.00 0.00 2.00 2.00 All "Other" Year 8 Children 284 190 0 0 186 186 67% 0.00 0.00 0.65 0.65 0.00 0.00 1.98 1.98 All Fluoridated Year 8 Children 154 94 1 0 137 138 61% 0.01 0.00 0.89 0.90 0.02 0.00 2.28 2.30 All Non-Fluoridated Year 8 Children 224 149 7 0 141 148 67% 0.03 0.00 0.63 0.66 0.09 0.00 1.88 1.97 Maori Fluoridated Year 8 Children 43 21 1 0 51 52 49% 0.02 0.00 1.19 1.21 0.05 0.00 2.32 2.36 Maori Non-fluoridated Year 8 Children 40 25 7 0 33 40 63% 0.18 0.00 0.83 1.00 0.47 0.00 2.20 2.67 Pacific Fluoridated Year 8 Children 8 5 0 0 4 4 63% 0.00 0.00 0.50 0.50 0.00 0.00 1.33 1.33 Pacific Non-fluoridated Year 8 Children 3 2 0 0 4 4 67% 0.00 0.00 1.33 1.33 0.00 0.00 4.00 4.00 Other Fluoridated Year 8 Children 103 68 0 0 82 82 66% 0.00 0.00 0.80 0.80 0.00 0.00 2.34 2.34 Other Non-fluoridated Year 8 Children 181 122 0 0 104 104 67% 0.00 0.00 0.57 0.57 0.00 0.00 1.76 1.76

Other comments Enter any other comments here that may help explain the Our most deprived families live in the Masterton area which corelates with the higher decay rates in the fluoridated areas. Of interest however is the higher figures provided. DMFT of the Maori yr 8's in the non fluoridated areas. i.e. if your going to get decay you get more in the non fluoride areas if you are Maori or Pacifica. Any year 8 children due in the last few months of 2016 were not seen in 2016 as our PP see all year 9's in the first couple of months of the school year. We If any of these results did not meet your DHB's targets, are working with the 2 local iwi providers targeting high risk Maori. you must provide an explanation here that includes a description of what your DHB is doing to rectify the problem.

28 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

Wairarapa DMFT Scores for 2016 – 5 Year Old Children

Five-year-old children, 2016____calendar year Number of Number of Decayed, Mean DMFT for children with caries Number of Number of Number of Teeth Number of Missing due Children Children % Caries Free Mean d Mean m Mean f Mean dmft Decayed Teeth Missing due Filled Teeth to caries Examined Caries-Free to Caries and Filled Mean Dental Health Status Teeth Mean d Mean m Mean f dmft All 5-year old Children 477 314 96 45 480 621 66% 0.20 0.09 1.01 1.30 0.59 0.28 2.94 3.81 All Maori 5-year old Children 138 73 68 25 214 307 53% 0.49 0.18 1.55 2.22 1.05 0.38 3.29 4.72 All Pacific 5-year old Children 20 8 15 1 23 39 40% 0.75 0.05 1.15 1.95 1.25 0.08 1.92 3.25 All "Other" 5-year old Children 319 233 13 19 243 275 73% 0.04 0.06 0.76 0.86 0.15 0.22 2.83 3.20 All Fluoridated 5-year old Children 233 139 32 32 282 346 60% 0.14 0.14 1.21 1.48 0.34 0.34 3.00 3.68 All Non-Fluoridated 5-year old Children 244 175 64 13 198 275 72% 0.26 0.05 0.81 1.13 0.93 0.19 2.87 3.99 Maori Fluoridated 5-year old Children 82 42 19 20 133 172 51% 0.23 0.24 1.62 2.10 0.48 0.50 3.33 4.30 Maori Non-fluoridated 5-year old Children 56 31 49 5 81 135 55% 0.88 0.09 1.45 2.41 1.96 0.20 3.24 5.40 Pacific Fluoridated 5-year old Children 12 3 4 1 22 27 25% 0.33 0.08 1.83 2.25 0.44 0.11 2.44 3.00 Pacific Non-fluoridated 5-year old Children 8 5 11 0 1 12 63% 1.38 0.00 0.13 1.50 3.67 0.00 0.33 4.00 Other Fluoridated 5-year old Children 139 94 9 11 127 147 68% 0.06 0.08 0.91 1.06 0.20 0.24 2.82 3.27 Other Non-fluoridated 5-year old Children 180 139 4 8 116 128 77% 0.02 0.04 0.64 0.71 0.10 0.20 2.83 3.12

Other comments Enter any other comments here that may help explain the The vast majority of our low decile patients are in the fluoridated areas. Masterton has 'higher' than the national average of deprivation. Masterton is our only figures provided. Fluoridated area. Please note the Maori children in the non Fluoridated area have higher decay than thier fluoridated colleagues even though on average they will have a lesser If any of these results did not meet your DHB's targets, deprivation scale. you must provide an explanation here that includes a We are working with our Maori providers at targeting all Maori 0-4 years of age and giving targeted Oral Health information to these families. We are description of what your DHB is doing to rectify the also working at DNA rates with the Maori womans welfare league. problem. We are currently providingoral health information group sessions for all 8-12 week old babies we anticipate this will lower the decay rates further. The Pacific children are such a small cohort that they are not statistically viable.

29 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

APPENDIX 2:

ACHIEVEMENT AGAINST WORK PLAN

Service design and development Action Areas (description) Traffic Deliverables Quarterly Identified Light Milestone(s) Risk/Narrative All children over 4 years of age Consent sent to Achieved are offered radiographs. Every caregivers. child has had a radiograph by Children at 6 years of age the age of 6. have received at least one radiograph

All new born babies and their All parents of new born Achieved caregivers are offered dental babies receive invitations health education sessions. to attend sessions.

Mobiles fully staffed. Staff Roster for mobiles full

Increase pre-school Provide information re Pacific Island enrolments. oral health enrolment to church at risk groups information day. Whaiora and Plunket engagement

Improve service culture and workforce development. Action Areas (description) Traffic Light Deliverables Quarterly Identified Milestone(s) Risk/Narrative Take on one dental student Otago student organised Student in term 3 over year.

One social event offered per Drinks after work once a Achieved term for staff. term.

Provide on-going appropriate CPD provided with local training PP’s and HVH.

30 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

Stakeholder relationships. Action Areas (description) Traffic Light Deliverables Quarterly Identified Milestone(s) Risk/Narrative Engage with Tamariki Ora providers. Lift the lip training Achieved

Establish relationships with Training session at attend church pacific groups church meeting groups.

Engage with local P.P’s Provide social and Social and information evenings CPD nights for local PP’s held

Quality

Action Areas (description) Traffic Deliverables Quarterly Identified Light Milestone(s) Risk/Narrative Quality fully embedded in staff Staff meeting Achieved meetings. minutes reflect each staff value placed on meeting. quality by staff.

31 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

PUBLIC

CPHAC/DSAC DISCUSSION PAPER

Date: 1 November 2017

Author Clare Munro, Senior Business Support Analyst, Regional Public Health Shane Bradbrook, Senior Public Health Advisor, Regional Public Health

Endorsed By Peter Gush, Service Manager, Regional Public Health Dr Stephen Palmer, Clinical Head of Dept., Regional Public Health

Nigel Broom, Executive Leader, Planning & Performance, Wairarapa DHB Helene Carbonatto, General Manager, Strategy, Planning and Outcomes, Hutt Valley Reviewed/approved DHB by Rachel Haggerty, Director, Strategy, Innovation and Performance, Capital & Coast DHB Chief Executives, Wairarapa DHB, Hutt Valley DHB, and Capital & Coast DHB

Subject Regional Public Health Update

RECOMMENDATION It is recommended that CPHAC/DSAC: a) NOTE issues, strategies and future focus in regard to environmental health – in housing, climate change, emergency management and preparedness and water quality. b) NOTE issues, strategies and future focus in regard to preventing long term conditions – in tobacco, alcohol, obesity, and other drugs (methamphetamine and synthetic cannabis).

1. PURPOSE

To provide an update of Regional Public Health (RPH) activities and to identify future activities.

2. BACKGROUND

Regional Public Health (RPH) is a sub-regional service with a range of contracts and funding lines. Its core contract with the Ministry of Health (MOH) is based on delivering five core public health functions for the populations of Wairarapa District Health Board (WDHB), Hutt Valley District Health Board (HVDHB), and Capital & Coast District Health Board (CCDHB).

∑ Health promotion: is the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions. ∑ Health protection: is a term used to encompass a set of activities within the public health function. It involves: Ensuring the safety and quality of food, water, air and the general environment. It also includes preventing the transmission of communicable diseases. ∑ Preventive interventions: includes a wide range of activities — known as ‘interventions’ — aimed at reducing risks or threats to health. Disease prevention and health promotion share many goals, and there is considerable overlap between functions.

Combined 3DHB CPHAC-DSAC Page 1 [month year]

32 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

PUBLIC ∑ Health assessment and surveillance: Public health surveillance is the continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice. ∑ Public health capacity development: enhancing our public health systems’ capacity to improve population health e.g. developing partnerships with Iwi, hapū, whānau and Māori to improve Māori health.

RPH also provides a range of other public health services. All services agreed with funders are summarised in the diagram below:

Capital & Coast and Hutt Valley District Health Board Page 2 [month year]

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PUBLIC As a Public Health Unit, RPH carries out unique, essential public health services every day. The following ‘wheel’1 shows a snapshot of the wide range of public health approaches undertaken.

3. CONTEXT

3.1 People and Place – a longer term perspective

The opportunity for health begins long before the need for medical care - in families, neighbourhoods, schools and jobs. To support optimal health and wellbeing, for all people in our rohe, RPH centres services on a holistic framing of health and wellbeing, people who face significant barriers to better health, and contributing to a long term impact. This means a focus on people (from beginning to end of life), their whānau, their communities, and their environments. It includes having on-going working relationships with many sectors, agencies and community groups that are actively seeking to make a difference with, and for, people who don’t have the same opportunity to be as healthy as others.

1 RPH quality assurance wheel Capital & Coast and Hutt Valley District Health Board Page 3 [month year]

34 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

PUBLIC

Capital & Coast and Hutt Valley District Health Board Page 4 [month year]

35 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

PUBLIC

The following extract is from the Royal Australasian College of Physicians (RACP), who recently released a health equity position statement ‘Make it the Norm.’2 It helps explain why a ‘whole of health and wellbeing’ (holistic) lens is vital for a district health board and their public health unit.

“… The RACP3 recognises health as multidimensional, encompassing more than just the treatment of illness and disease…

“As physicians and paediatricians we are treating patients who are struggling with preventable illnesses every day,” Dr Christiansen, the RACP President, explained. “We need more holistic approaches to addressing the social determinants of good health, including healthy housing, ‘good’ work and whānau wellbeing.”

Paediatrician and RACP New Zealand President-Elect Dr Jeff Brown agreed.

“I’m seeing an increase in repeat hospital admissions of kids with respiratory illnesses, including pneumonia, caused by living in cold, mouldy homes,” he said. “We treat them, and send them right back to the same unhealthy environment.”

Dr Christiansen said the evidence overwhelmingly supports action on the social determinants of health and requires a whole-of-society response. Central and local government, communities, non- government organisations and industry need to work together to support the health and well-being of all New Zealanders.

“Health and well-being must become the norm,” Dr Christiansen said. “Where people live, how they spend their time, and who they live with, all have a major impact on human health. The best way to enable health equity is to look at the conditions in which people grow, live, work and age, and how these can support positive health outcomes.… Ensuring whānau are supported to lead healthy lives by addressing the causes of poor health will lead to reduced costs for the health system and greater health equity.”

3.1.1 Key strategies Bridging between communities and agencies In every day work with, and for, communities and agencies, RPH often is ‘the bridge.’ - working alongside community leaders and other agencies to agree how to collectively make a difference. For example, in housing related work, RPH regularly brings together Housing NZ, the Ministry of Social Development and locally based providers such as the Sustainability Trust and Tū Kotahi Māori Asthma Trust.

Influence decision-making Collaborating with a range of organisations and planning forums. Some of the key areas include local and central government, the health system, urban planning, housing, water, transport, emergency management and preparedness.

2 Available from https://www.racp.edu.au/docs/default-source/default-document-library/make-it-the-norm- pres-letter.pdf?sfvrsn=6 3 The Royal Australasian College of Physicians (RACP) is a professional medical College of over 15,000 physicians and 7,500 trainee physicians, in Australia and New Zealand. Capital & Coast and Hutt Valley District Health Board Page 5 [month year]

36 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

PUBLIC Supporting the voices of people who are more vulnerable Community led action in neighbourhoods. For example, youth led action on smokefree cars and sports grounds.

Providing public health information and advice Examples of providing information to support action include: ∑ The RPH website (www.rph.org.nz) ∑ The Public Health Post, a quarterly newsletter to primary health practitioners ∑ Public Health Alerts detailing current health concerns e.g. mumps, measles and the Zika virus. ∑ Analysed public health data to a variety of stakeholders e.g. about the water quality of coastal, streams, rivers and drinking water supplies.

3.1.2 Future focus More focus on actively empowering people with the greater need, to be involved alongside agencies and decision-makers.

3.2 ENVIRONMENTAL HEALTH

3.2.1 Housing Key messages ∑ Poorly maintained, damp, mouldy, and cold housing is hazardous to health ∑ Overcrowding increases the spread of infectious diseases ∑ Since starting in April 2015, Well Homes (HVDHB and CCDHB) has received over 2,000 referrals.

The inability to access decent, affordable housing is one of the most significant barriers to an adequate standard of living. At a family level, housing represents the most significant single budget item for many New Zealanders. Additionally, the quality of housing directly affects people’s health, particularly in the case of children and old people. For children, security and adequacy of housing have far-reaching effects on their health, achievements in education and their general development.

In New Zealand, many houses are old, cold, damp, mouldy, poorly built with inadequate insulation and heating. Living in poor quality or inadequate housing is linked with specific conditions including: asthma and depression, rheumatic fever, meningococcal disease, and skin infections.

An ultimate aim is that all people have choices about being well-housed across the housing continuum:4

4 Source: http://www.makinghomeshappen.co.nz/the-housing-continuum/ Capital & Coast and Hutt Valley District Health Board Page 6 [month year]

37 CPHAC_DSAC Committee Papers 17 November 2017 - 2. DISCUSSION PAPERS

PUBLIC RPH provided the following diagram to CPHAC in 2012 papers about housing and health. It shows the relationship between housing related conditions, housing issues and interventions, intersectoral barriers, as well as their possible solutions. From this the Well Homes service has evolved as the main current housing programme delivered by RPH (see key strategies below),

Key strategies Well Homes partnership. Well Homes is a partnership formed between RPH, Tū Kotahi Māori Asthma Trust, Sustainability Trust and He Kāinga Oranga (University of Otago) to deliver housing assessments to a range of whānau, usually referred by health professionals but also by social services and community groups. Currently the partnership is contracted for delivery in the HVDHB and CCDHB districts.

Since its inception as an integrated housing programme in April 2015, Well Homes has received over 2,000 referrals; these are focussed around Māori and Pacific households and areas of social deprivation. From early 2017, an automated referral process agreed between Well Homes, HVDHB and CCDHB has resulted in an increase in referrals.

The Well Homes programme operates from a hub located at RPH and uses an in-house customised database to input data of consenting whānau who meet the criteria for the MOH’s Rheumatic Fever and Healthy Housing Initiative Expansion contracts. Public Health Nurses triage the referrals and whānau are visited by either a nurse or qualified housing assessor. Child health is a key focus and whānau are provided information to reduce overcrowding, mould, draughts and dampness and are offered interventions including insulation, heating, curtains, blankets, bedding and beds as appropriate. Whānau outside the eligibility criteria are offered alternative housing solutions.

The following graph, showing recent analysis of nine years of housing sensitive hospitalisation (HSHR children 0 – 14) by area unit across the region has confirmed the focus on Maori, Pacific and areas of socioeconomic deprivation.

Wairarapa Healthy Homes Wairarapa DHB contributes annually, along with several other funders, to the Wairarapa Healthy Homes (WHH) project run out of Masterton District Council. The WHH project has been running since 2004 and

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PUBLIC involves the installation of energy efficient retrofit measures into targeted Wairarapa homes. The community funding has been leveraged with the Energy Efficiency and Conservation Authority (EECA’s) various schemes to deliver the retrofit measures.

Comparing the sub regional rate of 15 hospitalisations per 1,000 HSHR, the top three area units in:

∑ HVDHB rohe are: Taita North (58), Glendale (>40), and Delaney (40); ∑ CCDHB rohe are: Canons Creek East (48); Canon’s Creek North (41); Cannons Creek South (37); ∑ WDHB rohe (only one in the top 25): Masterton East (28)

Funding for housing ‘interventions’ such as heaters and children’s beds, is sourced from philanthropic entities, most recently the Hutt-Mana Energy Trust. Well Homes has also set up a partnership with the Department of Corrections Rimutaka Prison using donated funds to purchase high quality children’s bedding sets, blankets, door snakes and fire bricks for whānau made by prison inmates. Over 59% of prisoners participate in industry training to reduce recidivism, and some whānau receiving these products are among the prison community.

Collaboration The affordability, quantity and quality of housing are topical in the news, and a key driver of health outcomes. There are many players in addition to the health sector. Well Homes is engaged across Ministry of Business, Innovation and Enterprise (MBIE), Ministry of Social Development (MSD), Housing New Zealand (HNZ), Energy Efficiency and Conservation Agency (EECA), Treasury, Councils etc. with the

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PUBLIC purpose of collaborating around regulatory, compliance and policy matters, funding interventions and sharing learning from Well Homes’ data.

Future focus Maintain current services Maintain an integrated housing programme, including the Well Homes partnership.

Influence decision-makers Influence decision-makers in health, housing and urban planning with a focus on improving the living environments of those at risk of housing related illnesses (respiratory and rheumatic fever), vulnerable infants/children/new mothers and priority populations affected by housing and social disparities. This includes working with local and central government to influence good urban design and planning. For example, at the end of July 2017, Greater Wellington Regional Council held a meeting with representatives from the above agencies with the purpose of coordinating a regional approach to housing. Well Homes experience was presented; there were at least two potential collaboration projects resulting from the meeting as well as a commitment from the agencies present to work together.

Client quote: Thank you sooo much for the wonderful heater that was given to our whānau home. One of the first comments my daughter made was ‘mum it’s not cold’. - Single mother of 3 young children.

3.2.2 Climate change Climate change is affecting New Zealand and the health of New Zealanders as many factors that contribute to our health and well-being are threatened by climate change. The effects of climate change will not be spread evenly across the population, exacerbating existing socioeconomic and ethnic health inequities. Well-designed policies to reduce global greenhouse gas emissions will not only limit climate change and reduce the associated risks to human health, but have the potential to improve population health and reduce health inequalities.

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5

5 Graphic source: NZ Herald http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11934626 Capital & Coast and Hutt Valley District Health Board Page 10 [month year]

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PUBLIC An expert report recently released by New Zealand's leading body for science, Royal Society - Te Apārangi6, includes the following info-graphic and summary showing how climate change will disrupt the ‘building blocks’ of our health.

Community Strong social ties support our health but communities may be disrupted if neighbourhoods are abandoned or relocated.

Well-being Mental outlook is important for health but repeated stresses from extreme weather and other impacts of climate change may take a toll on our well-being.

Water Clean water is essential for our health but droughts, floods and increased temperatures may lead to water contamination and toxic algal blooms.

6 The Royal Society of New Zealand is an independent, national academy of sciences, and a federation of scientific and technological societies. Capital & Coast and Hutt Valley District Health Board Page 11 [month year]

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PUBLIC Food We need healthy food but droughts, floods and changes in weather patterns increase risk of crop disease, food spoilage, shortages and contamination.

Air Clean air is vital for our health but changes in temperature and rainfall can increase air pollution and pollen allergens, which will increase the prevalence of respiratory problems.

Temperature Moderate temperatures make life and work comfortable but more hot days will increase heat stroke, aggression and heart disease, especially for outdoor workers.

Shelter We need adequate shelter for our health but some homes may become uninhabitable due to floods, erosion or fire.

Disease Avoiding disease is vital for our health but rates of infection are likely to increase. Tropical diseases like malaria or West Nile virus may establish in New Zealand.7

New information commissioned from the National Institute of Water and Atmospheric Research (NIWA) in 2017, projects that there will be significant impacts to the by 2090 if global emissions are not significantly reduced:

• Annual regional temperatures will increase by 3°C • Wellington and Wairarapa will experience significant increase in hot days • Frosts in the high elevations of the Tararua Ranges is likely to disappear • Spring rainfall will reduce by up to 15% in eastern areas • Up to 15% more winter rainfall could be experienced along the west coast • The risk of drought will increase in the Wairarapa • More extreme rainfall events8

Of the four ports monitored across New Zealand, the Wellington tide gauge showed the most marked trend with a rate of increase of 2.23 (±0.16) mm/year for 1891 to 1893 and 1901 to 2015.

Figure2: Change in annual mean sea level for Wellington (relative to 1986-2005 baseline average)

7 Source: Human Health Impacts of Climate Change for New Zealand Evidence Summary, Royal Society, 2017 8 Source: Climate change and variability - Wellington Region, NIWA, 2017. Available at http://www.gw.govt.nz/climate-change/ Capital & Coast and Hutt Valley District Health Board Page 12 [month year]

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9 Source: http://www.stats.govt.nz/browse_for_stats/environment/environmental-reporting- series/environmental-indicators/Home/Marine/coastal-sea-level-rise.aspx Capital & Coast and Hutt Valley District Health Board Page 13 [month year]

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PUBLIC Following are two examples of RPH service areas particularly relevant to climate change - emergency management and water quality. Services such as these contribute to the region’s resilience and preparedness for a changing climate.

3.2.3 Emergency management and preparedness Effective emergency management ensures that we have the capability to respond appropriately to emergency events where there are potential threats to public health. These include significant disease outbreaks, pandemics and physical events such as an earthquake or flood, or from a disease vector or an ill traveller coming across our border. Prompt and effective measures are required to protect the health of the public against injury, disease or illness arising from such emergencies.

RPH has a legislative and contractual relationship with the MoH and DHBs to provide public health services during all phases of an incident or emergency (reduction, readiness, response and recovery). Experience in New Zealand and overseas overwhelmingly confirms that the impact of emergency events on vulnerable communities is more significant than those communities who have greater resources and resilience. Many emergency management activities reflect RPH’s commitment to working collaboratively with other agencies and communities on preparedness and resilience building.

Local context Emergency Management The greater Wellington region has experienced a number of emergencies caused by hazards, including earthquakes, floods, landslides, drought and pandemics. It is likely that the region would face multiple hazards in any type of event, for example, an earthquake could result in transport disruption, landslides, tsunami etc, similarly, a high rainfall event may cause flooding, landslides and transport accidents. The region has some unique geological and geographic features and combined with human activity present a number of hazards.

Border Health The Wellington region contains two international points of entry. Wellington International Airport Limited (WIAL) and CentrePort Wellington Limited (CPWL). Both are designated points of entry under the International Health Regulations 2005 (IHR).

WIAL previously only operated Trans-Tasman international flights, however, the airport continues to expand and now operates twice weekly flights to and from Fiji and has recently introduced flights to Singapore via Canberra. CPWL is a cruise, log and container port with moderate shipping traffic. Approximately 60-70 cruise ships are expected to visit the port during the 2017/18 holiday season. The numbers of vessels first porting Wellington is fairly low compared to other large ports like Auckland and Tauranga, however, although delayed by recent earthquake damage, there are plans to further expand the operation in order to receive larger ships.

Effective border health planning, surveillance and response protocols ensure that RPH is able to minimise the risk posed to public health from diseases that may otherwise cross New Zealand's borders, for example, Ebola Virus Disease, Zika Virus, MERS-Cov, Wild Polio and Non Seasonal Influenza. Although services aim to protect the whole population, particular focus is given to protecting the most vulnerable groups. RPH continues to further develop excellent working relationships with our fellow border health agencies and stakeholders, e.g., NZ Police, NZ Fire Service, Wellington Free Ambulance, Customs, and the Ministry for Primary Industries.

In 2013 and again in November 2016, the Wellington region experienced earthquakes (centred in Seddon and Kaikoura), significant storm events and the threat of potable water shortages. The effects of technological failures affecting lifelines (water, electricity, infrastructure) and the impact on vulnerable communities (for example Māori, Pacific, Refugees, Housing New Zealand tenants, children, elderly) were highlighted in these events. RPH worked hard during the lengthy electricity outages caused by the June 2015 storm to ensure that the welfare needs of the vulnerable were being met.

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In May 2015, Emergency Operations Centres were activated in Kāpiti, Hutt and Porirua. Heavy rains caused a small landslide on State Highway 1 that blocked the route between Kāpiti and Porirua and caused a number of rivers and streams in the region to rise which combined with surface flooding caused damage to homes and businesses around the region. We provided advice during this event particularly with regards to drinking and recreational water matters and clean up information for those affected with flooded properties. These events highlighted the regions risks to the strong possibility that areas may be cut off in emergencies due to Wellington’s main transport corridors, both road and rail, being in a Y shape, with few links between the main arterial routes.

In October 2015 flooding in the Upper Hutt area caused the Birchville Bridge to collapse resulting in a 10 hour shutdown of the city water supply to 70 properties and a temporary water supply (via fire hoses) for a further 5-6 days.

The above responses were an opportunity for RPH to demonstrate the role of public health in an emergency, in particular ensuring that the welfare needs of vulnerable groups were met.

Key strategies RPH continues to undertake weekly mosquito surveillance in and around our two main points of entry (fortnightly in winter) and maintain the ability to respond to interceptions/incursions as and when required. Although the climate and frequent high winds in Wellington are not favourable to exotic species at present, the continued progress of global warming and the expansion of international travel mean that the threat of exotic species becoming established in Wellington cannot be underestimated (Zika Virus, Chikungunya and Dengue Fever are present in the Pacific Islands).

Current work aims to strengthen and enhance emergency preparedness, response and recovery. This includes providing support to local marae to enhance resilience of the marae following an emergency event.

RPH gives high priority to maintaining strong links with DHB emergency planners and the regional Emergency Services Co-ordinatoring Committee (ESCC). RPH was instrumental in ensuring that the Wellington ESCC re-started in 2015 and are proactively seeking the Hutt Valley ESCC to restart. We will continue to foster relationships with Wellington Region Emergency Management Office (WREMO) and other emergency services, including participating in regional exercises. RPH is represented on the Regional Welfare Advisory Group and continues to actively be involved in welfare planning.

Future focus RPH will continue to focus on engagement with key health providers, emergency response agencies, welfare agencies and communities across the sub-region to enhance health sector emergency preparedness.

RPH is committed to supporting resilience for vulnerable groups and will continue to work to strengthen and enhance resilience following an emergency event.

3.2.4 Water Quality

RPH activities actively encourage healthy water supplies and safe recreational water management practices that promote good health for our communities. RPH works at a high level (influencing regional and national policy) as well as through targeted local activities, such as involvement in the Porirua Harbour Project. RPH is committed to strengthening relationships with Iwi and hapū in the region to support their active engagement in maintaining healthy environments. This includes working directly and indirectly with tāngata whenua to maintain the integrity of recreational water bodies and traditional food sources. A healthy water body will sustain healthy ecosystems, support a range of cultural uses and reinforce the cultural identity of Māori.

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PUBLIC Drinking Water A safe and adequate supply of drinking water is a prerequisite for good health. Many small rural New Zealand communities, including marae, do not have access to drinking-water that is known to be safe. These communities are specifically targeted through the Drinking-Water Assistance Programme which provides technical assistance to help improve their water supplies. Larger water supplies are audited to ensure their risk identification and mitigation plans are adequate and being implemented, and that their operators are competent in the use of drinking water quality monitoring tools. An important aspect of this work is working with drinking water suppliers when monitoring shows microbial contamination. A good understanding of how the drinking water supply has become contaminated is essential to clearing the contamination and preventing a reoccurrence.

Recreational Water Recreational water activity seeks to prevent the risk of disease associated with the public use of recreational waters and also optimise the social and physical health effects of this part of the environment. In addition, many discharges to fresh and marine waters pose a threat to health through contamination of food sources. Many of these food sources (e.g. shellfish, watercress) are collected as a traditional food source by many ethnic groups who are therefore at greater risk of illness.

Local Context Greater Wellington Regional Council manages 320 kilometres of river channels and 280 kilometres of stopbanks and is responsible for one of the largest flood protection schemes in New Zealand.

While the Wairarapa has a smaller population, there are increasing challenges in minimising public health impacts in relation to drinking water supplies and land use.

About 155 million litres of high quality drinking water is treated and delivered by Wellington Water each day, on average, to the Wellington, Hutt, Upper Hutt and Porirua City Councils. There are a number of smaller council run supplies on the Kāpiti Coast and in the Wairarapa as well as community and individual supplies.

Key Strategies Protection of water catchments such as Kaitoke and Wainuiomata is vital to ensure that the drinking water for our major communities continues to meet the Drinking-Water Standards of New Zealand requirements.

Fluoridation of public water supplies. This is a topical issue nationally and regionally. RPH works with territorial local authorities and DHBs to promote the fluoridation of drinking water supplies and ensure they have accurate scientific information about the risks and benefits of water fluoridation.

Ensuring adequate controls are placed on wastewater discharges to fresh and marine waters and that the public health risks of contamination of recreational waters are mitigated.

Future focus Following the investigation into the recent contamination of the drinking water supply in Havelock North, the Inquiry Panel is due to provide the Stage Two Report by early December 2017. As at 30 June 2017, of the twenty two water supplies in the region, fifteen did not fully comply with the New Zealand Drinking Water Standards. Many of these are in the Wairarapa area. We are working with these suppliers to help them become fully compliant.

3.3 PREVENTING LONG TERM CONDITIONS

Strategic and operational plan for the prevention of long term conditions

Long Term Conditions (LTCs) are:

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∑ the leading cause of health loss in New Zealand ∑ associated with high healthcare costs and ∑ contributing to ethnic inequalities in health.

As the population grows and ages, the increasing burden of LTCs on society and the healthcare system will become unsustainable.

Potentially, one third of health loss can be prevented by minimising exposure to four shared risk factors: tobacco, diet, alcohol and physical inactivity. However, these risk factors do not exist in isolation, and are strongly influenced by the environment and societal conditions such as income, housing, poverty and education. In order to prevent LTCs the wider determinants of health need to be considered and addressed.

The proposed Framework for Prevention of Long Term Conditions (see below) draws on international, national and regional tools, plans and frameworks, including:

∑ the WHO Global Action Plan for the Prevention and Control of Non-Communicable Disease; ∑ the Ottawa Charter for Health Promotion; ∑ Dahlgren and Whitehead model for Social Determinants of Health; ∑ Canadian Tool for Chronic Disease Prevention; ∑ the New Zealand Health Strategy; ∑ the MoH Outcomes Framework for LTCs and ∑ Māori models of health.

The Framework outlines: why, who, what, where and how for the prevention of LTCs. It also sets out eight proposed key intervention domains:

1. Social determinants of health 2. Psychological status and behaviours 3. Diet 4. Physical activity 5. Alcohol 6. Tobacco 7. Quality data and surveillance 8. Natural and built environment

These intervention domains are supported by key guiding principles:

∑ Equity life-course ∑ Evidence-based ∑ Multisectorial/collaborative practice ∑ Population based

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3.3.1 Tobacco Key messages ∑ Support and contributes to the advancement of the Smokefree Nation 2025 goal. ∑ Reduce daily smoking prevalence rates to <5% by 2025. ∑ Increase public support for the overall goal of a Smokefree Aotearoa by 2025.

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∑ Increase compliance and awareness of the Smokefree Environments Act 1990. ∑ Increasing successful smoking cessation quit rates. ∑ Support the 'Better Health for Smokers to Quit' target within primary and secondary care settings. ∑ Tobacco use is a major contributor to health inequities for Māori, Pacific peoples, and lower socio-economic groups.

In March 2011 the government adopted the Smokefree Nation 2025 goal. This was in response to the recommendations of the landmark parliamentary inquiry into the tobacco industry by the Māori Affairs Select Committee. All RPH’s tobacco control efforts are making a contribution to this goal.

Tobacco smoking is a major public health problem in New Zealand. It is estimated that smoking annually kills around 4500-5000 people, of which over 600 are Māori. Smoking is the main cause of lung cancer and is a prominent risk factor for chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD), upper aero digestive cancers (includes cancers of the mouth, oesophagus, pharynx and larynx), and many other cancers and chronic diseases.

Tobacco use is recognised as a major contributor to health inequities. Māori, Pacific peoples and those in lower socioeconomic groups have much higher rates of smoking and higher rates of ill-health and death from both smoking and passive smoking. The health burden attributable to tobacco smoking prevalence is higher amongst those within low socio-economic position where Māori are over- represented.

National context

Smoking prevalence rates in New Zealand from 1983 to 2015 (Sources: Tobacco Trends 2008: A brief update of tobacco use in New Zealand, Ministry of Health, 2008; New Zealand Health Survey, Ministry of Health, 2012; Year 10 Snapshot Survey, Action on Smoking and Health)

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Smoking prevalence rates by ethnicity (Source: 2013, )

Smoking prevalence rates by DHB (Source: New Zealand Census 2013, Statistics New Zealand)

Regional context Primarily the intention is to work within geographical areas that meet criteria that reflect communities with a higher proportion of Māori, Pacific peoples and low income earners. This intent will be inclusive of sub-groups such as pregnant women and children and youth.

There are approximately 550 tobacco retailers across greater Wellington. Locally RPH knows that 4974 Māori in the Capital & Coast region, 4587 in the Hutt Valley and 410 in the Wairarapa are regular smokers. The Hutt Valley at 34.4% and Wairarapa at 36% are above the national average of 32.7%. Capital & Coast smoking prevalence rate is at 26.2%.

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PUBLIC Key strategies ∑ Supporting smoking cessation quit programmes ∑ Achieve set government targets ∑ Establishing and improving referral pathways for smokers to quit with support ∑ Enforcement of sales to minors ∑ Promote Smokefree Nation 2025 ∑ Events: attend and/or support targeted events with health promotion messaging on banners, tents

Future focus Tobacco-free retailers Investigate working with retailers to remove tobacco products for sale.

Smokefree enforcement This activity builds on ongoing compliance with the Smokefree Environments Act legislation. Work has focused on providing educational sessions with retailers prior to conducting enforcement operations. Targeting areas on both geographical basis and communities with high numbers of Māori, Pacific peoples and low income populations will occur.

Strengthening alliances The Smokefree/Tobacco-free Network will expressly coordinate, and provide secretariat support, activities that contribute to Smokefree Nation 2025.

Smokefree settings RPH will continue to support and provide advice on extending smokefree environments e.g. outdoor spaces, streets etc with the regions Councils.

Better help for smokers to quit RPH will focus on supporting highly vulnerable Māori and Pacific communities in quit attempts. RPH will work alongside external providers to optimise quit rates.

3.3.2 Alcohol Key messages ∑ Reduced number of alcohol outlets in communities of high Māori, Pacific peoples and/or low socio-economic populations ∑ No alcohol sales to minors within communities of high Māori, Pacific peoples and/or low socio-economic populations ∑ Communities are supported to prevent alcohol related harm

Alcohol related harm is suffered disproportionately by certain groups in the New Zealand population, including those with low socio-economic status, Māori, Pacific peoples and young people. RPH aims to reduce the higher levels of hazardous alcohol consumption exhibited by these groups. Hazardous drinking rates have risen back to 2006/07 rates.

Geographic areas that have high Māori, Pacific peoples, young persons and/or low socio-economic populations will be prioritised. To reduce alcohol related harm we need to address the New Zealand drinking culture. This requires multiple strategies at national, regional and local levels. Activities will include: ∑ both health protection and health promotion strategies ∑ be responsive to local needs ∑ look to maximise any gains occurring at a national level.

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PUBLIC National context The Ministry of Health 2014/15 New Zealand Health Survey [Hazardous drinking in New Zealand] found that: ∑ 25% of men were hazardous drinkers compared with 11% of women ∑ Hazardous drinking rates peaked among young adults (43% of men and 24% of women aged 18–24 years), and decreased thereafter. By the age of 75 years and over, hazardous rates decreased to 5.4% of men and 0.8% of women. Young adults (aged 18–24 years) also had the highest rate of drinking six or more drinks on one occasion (binge drinking) at least weekly (19%) ∑ About one in three Māori adults (32%) had a hazardous drinking pattern, as did 23% of Pacific adults. Despite relatively low rates of Pacific adults drinking alcohol in the past year, Pacific adults were more likely to have a hazardous drinking pattern than non-Pacific adults, after adjusting for age and sex differences. Over half of male Pacific drinkers (52%) were hazardous drinkers. Asian adults (5%) were much less likely to be hazardous drinkers than non-Asians, after adjusting for age and sex differences ∑ Adults in the most socio-economically deprived areas were more likely to be hazardous drinkers (23%) than those in the least deprived areas (14%).

Regional context There are over 1,500 individual license holders in eight territorial authorities across greater Wellington. Each of these areas is unique and has its own characteristics relating to demography, supply and harm issues. RPH staff work with a range of networks to address identified issues, provide advice and give guidance on harm reduction practice.

Alcohol harm is greatest in areas of high outlet density. Density issues are primarily of two different types, those in central city areas catering for entertainment and those in residential areas with high numbers of off licenses. Both are of concern for RPH.

Work priority for this activity plan focuses on high license density in the Wellington entertainment district and residential areas of high social deprivation and/or high health impact (i.e. Eastern Porirua, Newtown, Naenae, and Wainuiomata). RPH will work directly with these communities and support existing networks in those communities.

Alcohol harm reduction uses a widespread approach that includes intervention to change both physical and social environments. The approach empowers local communities to take ownership and promote change.

RPH is one of only a few agencies that has staff working in the area of harm reduction that have responsibility for service delivery throughout the region rather than working in smaller geographical settings. RPH is constantly gathering public health intelligence to improve harm reduction techniques.

Key strategies A region free from the harm of alcohol is the ultimate goal. Significant change in hazardous drinking levels in our priority populations is not expected in the short-term. Goals that alter the environment are achievable in the short-term and should sit alongside strategies that in the longer term will infiltrate the public's perceptions of that culture.

RPH will respond to the needs of the populations most at risk of harm from alcohol misuse. This means finding ways to improve RPH engagement with Māori and Pacific communities as well as youth. Where possible, efforts will be made to support improved sector integration across alcohol, tobacco and other drugs work.

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PUBLIC Future focus Harm reduction There is ongoing work towards reducing alcohol and other drug related harm in the greater Wellington region. This work builds on our legislative requirements under the Sale and Supply of Alcohol Act 2012 and partnering with health promotion initiatives to maximise positive outcomes for our communities.

Wellington Regional Hospital Emergency Department data Work is ongoing to develop a process to receive and analyse data collected from Wellington Hospital Emergency Department. As of the 1st July 2017 all Emergency Departments are required to collect this data. Over time this will provide clarity regarding alcohol related harm occurring across our region and help support RPH interventions.

Strategic planning RPH is reviewing its strategic direction with a view to formalising a three to five year plan.

Submissions Provide evidential support for community initiated calls for challenging alcohol licensing applications in areas of high Māori and Pacific populations.

3.3.3 Obesity (Nutrition/Physical activity) Key messages ∑ Environments influence individuals to make the healthier choice the easier choice to make ∑ Poor diet has overtaken tobacco smoking as the greatest risk to health loss (Ministry of Health, Health loss in New Zealand 1990-2013, a report from the New Zealand Burden of Disease, Injuries and Risk Factors Study - 2016) ∑ Empower people in the Wellington region by focusing on communities where the potential for health gains are the greatest, to make healthier food choices as recommended by the Ministry of Health Food and Nutrition Guidelines ∑ Māori and Pacific adults and children alike (and those living in the most deprived areas) have disproportionately higher rates of obesity and non-communicable diseases than the general population.

The increasing prevalence of low nutritional value diets and sedentary lifestyles are major contributing factors of the growing obesity epidemic and rising rates of non-communicable diseases such as type two diabetes, cardio-vascular disease, osteoarthritis and some cancers.

Obesity rates in New Zealand are among the highest in the OECD, with the 2012/13 New Zealand Health Survey finding almost one in three adults aged 15 years and over (31%) to be obese and a further 34% overweight. The survey also found one in nine children aged 2-14 years (11%) to be obese and one in five (22%) to be overweight.

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Unequal experience of obesity The 2012/13 New Zealand Health Survey shows 48% of Māori adults, 19% of Māori children, 68% Pacific adults and 27% Pacific children are obese. It also identified that children living in the most deprived areas were three times as likely to be obese than children in least deprived areas. This finding is not explained by differences in the sex, age or ethnic composition of the child population across areas of high and low deprivation and suggests some direct correlation with the experience of deprivation.

RPH seeks to address these inequalities in a number of ways including focussing on: ∑ the broader food/physical activity environment, especially low socio-economic communities e.g. East Porirua and Wainuiomata to increase the opportunities for healthy behaviour choices for residents of these communities ∑ relationships/partnerships with groups and organisations which are kaupapa Māori led or Māori/Pacific based e.g. Wesley Community Action; Pacific Health Services; Wainuiomata Valley Church Samoan congregation; Wellington Early Childhood Pacific Collective ∑ resources meeting the needs of the Māori/Pacific communities, e.g. translation of Fruit and Vegetable Cooperatives information into Samoan (and where relevant other languages) ∑ involving mainly Māori and Pacific participants in a cooking lesson pilot.

Issues with accessing healthy food Food security (the state of having reliable access to a sufficient quantity of affordable, nutritious food), is increasingly an issue with growing numbers of children, adolescents and adults regularly experiencing the inability to access adequate, safe, affordable and acceptable foods. Findings from the 2008/09 New Zealand Adult Nutrition Survey found that since 1997 food insecurity has increased for males by 1.6- 5.6% and for females by 3.8-8.8%. The total proportion of households experiencing low food security is 7.3% and a there is a 25% decrease in those living in food secure households. The results showed that the levels of food insecurity were significantly higher for Māori and Pacific, with Māori adults being over two times, Pacific males four times and Pacific females three times more likely to live in a household with low food security, than those who are not Māori or Pacific.

The influence of the food environment The causes of obesity and its associated preventable chronic diseases are multifaceted and complex. A recent analysis (Vandevijvere and Swinburn 2014) considered different scenarios for decreasing prevalence of childhood (2-14 years) obesity of 25% by 2025 in New Zealand. It will be an enormous challenge to reach this target by 2025 (Australia is now at this level) and reduce, or at least not increase, inequities across ethnic groups at the same time. This suggests two broad approaches are needed:

∑ community-based interventions which prioritise at risk populations and ∑ broader policy/regulatory approaches.

RPH has prioritised working in this area through the development and co-delivery of Fruit and Vegetable Cooperatives across the Wellington sub-region and the development and testing of implementation methodology for healthy food and beverage policies for large influential organisations. Growth in these work areas will be a key future focus.

Low physical activity levels Only 54% of adults In New Zealand meet the minimum recommended level of physical activity (with physical inactivity levels being higher for women) while Pacific and Asian adults have lower levels of physical activity than other groups, along with those living in the most deprived areas. According to the Youth 2007 report sedentary activities are common among secondary school students. The proportion of students watching more than one hour of television each day increased from 55% in 2001 to 73% in 2007, with levels of television watching being higher for Māori children than non-Māori children.

Government initiatives

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PUBLIC The key initiative for addressing the causes of obesity at the systems level is through the pilot contracts of Healthy Families NZ in 10 key communities around New Zealand; Hutt City Council leads Healthy Families Lower Hutt. Through RPH’s sector networks and relevant programmes we are working in collaboration to assist in the delivery of each other's goals while being cognisant that the remaining communities in our area of responsibility do not have access to this extra resourcing.

National context ∑ Good nutrition, regular physical activity, and a healthy body size are important in maintaining health and wellbeing and for preventing serious health conditions such as cardiovascular disease, diabetes and some cancers. ∑ Obesity rates in New Zealand are rising with two in three New Zealand adults overweight or obese. Māori are almost twice as likely to be obese as non-Māori while Pacific adults are 2.5 times as likely to be obese as non-Pacific adults (Ministry of Health, 2013). ∑ Obesity prevalence of New Zealand children continues to increase. ∑ From conception to childhood, parents/caregivers, families and communities directly shape a child's physical and social environment and indirectly influence behaviours, habits, preferences and attitudes. (Source: www.hpa.org.nz/what-we-do/nutrition-and-physical-activity )

Regional context Prevalence of Obesity in the Wellington Region 2007 to 2014

(Source: Greater Wellington Regional Council Wellington Region Genuine Progress Index http://www.gpiwellingtonregion.govt.nz/outcomes/social/healthy-community/obesity/)

Findings of the Greater Wellington Regional Council Wellington Region Genuine Progress Index:

∑ In 2014, 27.2% of the Wellington region adult population were classified as obese. ∑ The percentage of adults in the Wellington region who were obese increased from 25.0% in 2007 to 27.2% in 2014.

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PUBLIC Key strategies Fruit and Vegetable Cooperatives Following a successful pilot in Porirua East (May to December 2014) RPH has worked in partnership with Wesley Community Action to co-deliver the expansion of the ‘FoodTogether’ model, using a community led process, across the Wellington region. Efforts have focussed on working with groups in communities with affordability and accessibility issues to fruit and vegetables. There are hubs running in 10 locations (East Porirua, Titahi Bay-Tawa, Miramar-Strathmore, Waiwhetū-Petone, Wainuiomata, Naenae- Pomare-Taita-Stokes Valley, Upper Hutt-Timberlea, Kāpiti-Paraparaumu, Victoria University of Wellington) providing over five tonnes of locally sourced fresh fruit and vegetables weekly.

National DHB Food and Drink Policy RPH has supported the development and implementation of this policy developed by the DHB Healthy Food and Drink Environments Network and/or public health representatives from all DHBs, along with the MOH, with the intent that it would be able to be implemented over a two-year period by most DHBs. This national collaboration resulted in a robust policy that provides national consistency for food vendors and food suppliers throughout the country, streamlining the work food companies would need to do to align with product composition and size. The MOH has adopted the policy and it is available for all individual DHBs to consider. A similar policy appropriate for adoption by other organisations and workplaces has also been developed.

Nutrition policy in other organisations RPH is working with Victoria University of Wellington, to develop a Food and Drink Policy for the campus endorsed by the Board. Support was provided with writing and presenting a proposal to the VUW Wellbeing Steering Group. Preliminary discussions with other organisations, such as local councils, have been held to further expand this work in the food environment in the 2017/18 working year.

3DHB Food and Beverage Environment Guideline Implementation of the 3DHB “Healthy Food and Beverage Environment Guideline” has been completed at WDHB, HVDHB, and CCDHB. An implementation group including representatives from the three DHBs guided and supported the implementation process. With the National Food and Drink Policy document also completed, there is consideration regarding how the three DHBs align, or partly align, with the National DHB Policy. A 'working group' from the Implementation Group has been evaluating the current Guideline to determine what challenges and successes the food providers are having. The findings will inform the decision whether to align more closely with the national policy.

RPH has specifically provided support to the Hutt Hospital Food Services to change menus, recipes and be involved in successful implementation of the 3DHB guideline in the cafeteria, as the service did not have a dietitian or nutritionist.

Water-Only Schools Policy RPH undertook a survey of all 201 schools in the sub-region with primary aged children. This has led to the development of the ‘Water-only in Schools’ toolkit and webpage, hosted by RPH.

The survey received a 39% response rate (78 schools). Most supported ‘water-only’: 22 (28%) had implemented a policy; 10 (13%) were in the process of doing so; 22 (28%) were considering it; and 12 (15%) were ‘water-only’, but did not have a policy. Only 12 (15%) were not considering a ‘water-only’ policy.

This project could not have been achieved without the collaborative efforts of: ∑ Healthy Families (HVDHB) ∑ Healthy Futures (CCDHB) ∑ The Heart Foundation ∑ Ministry of Education, and ∑ Regional Dental Service Community and voluntary food sector Capital & Coast and Hutt Valley District Health Board Page 26 [month year]

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PUBLIC A scoping paper has been developed to explore the challenges and opportunities of the local charitable food sector to support optimal nutrition and well being of people who are food insecure. This paper is to be shared more widely to engage the sector in identifying and gaining a greater understanding of ways to optimise this vital nutrition lifeline.

Stakeholder relationships RPH continue with regular contact with physical activity and nutrition providers, including public health dietitians, Childhood Prevention of Obesity, the Regional Nutrition and Physical Activity Network and type two diabetes groups to support improved physical activity and nutrition in the greater Wellington region. Regular contact and collaboration has continued with local councils.

Physical activity opportunities RPH provides support for other physical activity initiatives such as North-East Pathways Project and leading the establishment of the Porirua Sport-fest in partnership with Sport Wellington and Sport NZ. RPH can optimise its working relationships with education groups, councils (e.g. Hutt City Council sports and recreation team) and community based groups to maximise the inclusion of physical activities.

Active transport RPH continued to work with the transport sector to increase physical activity opportunities, in particular in our targeted communities. RPH also supports various active transport initiatives including Active a2b, Walk to Work Day and Bike to Work Day.

Future focus Fruit and Vegetable Cooperatives Maintaining and expanding Fruit and Vegetable Cooperatives.

Water in schools Supporting and guiding ‘Water in Schools’ programme.

Policy Garnering support for the adoption of the National Food and Beverage Policy within DHBs and local councils. Influencing educational settings such schools, Te Kohanga Reo, Kura, Early Childhood Centres etc will be advanced.

Position paper Develop position paper on Sugary Drinks Tax.

Innovative initiatives Investigate new approaches and initiatives that could be adopted into our region e.g. Whānau Pakari: http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11935210

3.3.4 Other drugs – Methamphetamine Key messages ∑ Harm minimisation approach for users of methamphetamine ∑ Focus on treatment and support

Methamphetamine is a potent and addictive stimulant drug which can be smoked, snorted, injected or ingested orally or anally. Smoking as a powder is common in New Zealand; however researchers have noted indications that injecting methamphetamine is becoming more popular. The changing patterns of methamphetamine use have been referred to as ‘waves’, and New Zealand has been described as experiencing the ‘second wave’ of methamphetamine use currently. Methamphetamine induces a state of euphoria, increased wakefulness, energy and sex drive, and decreased appetite. The effect of

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PUBLIC methamphetamine can last up 12 hours, which is significantly longer than other stimulant drugs, for example cocaine’s effects last around 30 minutes (Source: National Institute on Drug Abuse, 2009).

The most recent government statistics show that overall numbers of methamphetamine users in New Zealand have been dropping. 0.9% (26,400 people) used the drug once or more in 2014/15, down from 2.2% in 2009. Around one fifth of those took the drug monthly or more, according to 2013/14 data. There is limited data collection regarding methamphetamine prevalence rates within the regional context.

Key strategies Based on research, an approach addressing methamphetamine harm needs to: ∑ Focus on non-stigmatising treatment and support ∑ Build protective factors and community resilience, that prevent methamphetamine harm in vulnerable communities; as per the Methamphetamine Action Plan, 2015 ∑ Ensure medical and social support for methamphetamine rehabilitation is accessible, and supports are in place up to two years after quitting

Focus on harm minimisation such as: ∑ Provide current methamphetamine users with appropriate sexual health services and contraception ∑ Preventative messages to methamphetamine users to not inject ∑ Provide access to clean needles and equipment for methamphetamine users who inject.

Future focus Community focus Support community initiatives to support methamphetamine users and recovering users, in a non- judgmental environment. This may be support groups of methamphetamine users and ex-users, or a ‘walk-in’ system. RPH will continue working with the Hutt Valley community (note comments below in 3.3.5 re the CAYAD contract) to strengthen protective factors.

De-stigmatisation Contribute to de-stigmatising methamphetamine users, with the aim of focusing the message on seeking help.

Mapping Mapping of addiction services for CCDHB and HVDHB needs to be undertaken with a specific focus on: ∑ The service’s ability to respond to referrals within appropriate timeframes ∑ Levels of treatment services available for low to high needs methamphetamine addiction ∑ Investigate access to services such as needle exchange and sexual health services for methamphetamine users.

3.3.5 Other drugs – Synthetic cannabis Key messages ∑ Synthetic cannabis is a dangerous and unpredictable drug ∑ Harm minimisation approach for users of synthetic cannabis

Synthetics are a class of drug which are synthesised synthetically. There are two common ‘synthetic’ drugs used in New Zealand. ‘Synthetic cannabis’ is a drug which resembles cannabis, but is plant matter sprayed with synthetic cannabis and/or other chemicals. Synthetic cannabis is usually smoked, but the effects of the drugs and the harm varies depending on which psychoactive or poisonous substances have been used.

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PUBLIC Synthetic cannabis products were legal until the Psychoactive Substances Act 2013. The ban has resulted in a black market supply of the product. These substances are manufactured overseas with no safety standards, and shipped to New Zealand. These substances contain untested and often toxic compounds.

Synthetic cannabis is a dangerous and unpredictable drug. The recent deaths in Auckland and subsequent media attention focused on the dangers of synthetic cannabis may change public perception. If the public are aware of the dangers of the drug, education might not be an effective measure to take to reduce harm. In addition to these reports, there have been reports of increased hospital admission for psychosis.

(Link: http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11897763)

There is no data collected regarding synthetic cannabis prevalence rates within the national and regional context.

Key strategies ∑ Community/youth education about synthetic cannabis ∑ Encourage community discourse about synthetic cannabis ∑ Harm minimisation for users of synthetic cannabis

Future focus RPH works primarily with our Hutt Valley focused Community Action on Youth and Drugs (CAYAD) team that sits within RPH, in providing regional and national oversight. RPH supports the following recommended national CAYAD approach to synthetic cannabis:

Community engagement Engage with and support organisations/community groups to plan and deliver community action initiatives to reduce alcohol and other drug related harm affecting young people.

Health promotion Design, deliver and support awareness-raising activities that provide opportunity for informed discussion and debate, increase knowledge and/or create behaviour change around the use of alcohol and other drugs.

Submissions Provide position papers/submissions to cannabis reform debate and to the Psychoactive Substances Act 2013 review in 2018-19.

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CPHAC/DSAC INFORMATION PAPER

Date: November 2017

Author Lindsay Wilde – Service Manager, Regional Screening

Endorsed by Dale Oliff – Chief Operating Officer Dr Ashley Bloomfield – Chief Executive

Reviewed/approved by Madeleine Wall, Clinical Director Regional Screening

Subject Regional Screening Services Update

RECOMMENDATION It is recommended that CPHAC/DSAC: a) NOTE the contents of this paper

APPENDICES -

1. PURPOSE

This report informs CPHAC/DSAC about Regional Breast and Cervical Screening Services and provides an overview of the work underway to address equity issues for our priority women.

2. BACKGROUND

2.1 Breast Screening

New look Breast Screening rebrand

The objective of the national breast screening programme is to find breast cancers early and therefore reduce the morbidity and mortality for women. To achieve this we aim to screen all eligible women every two years and this is free of charge.

HVDHB operating as BreastScreen Central (BSC) holds a Breast Screen Aotearoa (BSA) contract for screening women in the Wellington subregion. This contact covers Hutt Valley, Wairarapa and Capital and Coast DHB regions and is one of eight breast screen providers across the country. The contract is worth around $5.550 million per annum, the bulk of which is for the delivery of the mammography services and the rest for regional coordination and some fixed funding. We have been working on the renewal of our contract with BSA which will change to a results based accountability contract (RBA) in January 2018; we are currently in an interim rolled-over contract until then.

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Breast screening services in NZ started screening eligible women aged 50 – 64 years in December 1998. The service was extended to include women aged 45-49 in 2004. BSA (as per Ministry request) is currently investigating the potential for extending the age range to 74 years.

BSC has a number of fixed screening sites (Hutt base and Kenepuru Hospitals), two subcontracted sites with Pacific Radiology (PRL) at Wakefield Hospital and on Lambton Quay and a mobile screening unit that mainly services outlying areas such as Wairarapa and Kapiti but also supports other areas within the region as required.

Our goal is to provide and maintain a coverage target of 70% of the eligible population. A key focus for breast screening is targeting the unscreened or under-screened priority women and ensuring that there is not a duplication of effort with other providers. Māori and Pacific women are our key priority groups and the hardest to reach, engage, educate and screen and thus achieve target rates and health equity.

To achieve equity for high needs populations, the service undertakes data matching with PHOs to identify women who are under-screened or not screened. The Team has developed programmes to encourage these women to attend screening including targeted Saturdays, working in collaboration with Primary Health Organisations, General Practices, Māori and Pacific Providers (Mana Wahine Alliance and the Central Pacific Collective), providing support and transport to bring women in to screen, education and attendance at health promotion events, proactive follow-up of women who “do not attend” (DNA), liaising with community groups and other providers, and using all links available to see and screen women.

2.2 Cervical Screening

New look Cervical Screening rebranding

HVDHB also has a contract with the National Cervical Screening Programme (NCSP) to provide regional coordination, liaison, registration, management and operation of the NCSP-Register, invitation and recall, smear taking (capped volumes) and colposcopy (capped volumes related to the cervical screening programme), again across the 3 sub-regional DHBs. The National Screening Unit (NSU) in conjunction with regional screening services and working closely with providers and DHBs aims to reduce the incidence and mortality of cervical cancer.

The NCSP Priority Group women are Māori, Pacific, Asian and under-screened eligible women over the age of 30 who have not had a cervical smear for five years or un-screened women, eligible women over the age of 30 who have never had a cervical smear. The service also works closely with our migrant women populations to increase participation in the cervical screening programme.

Cervical Screening is for eligible women 20-69 years every three years. The coverage target is 80% for all ethnicities and this measure is proving difficult to achieve. We are working closely with PHOs, General Practices, Māori, Pacific, Asian and Migrant Services by providing support and transport to bring women into cervical and colposcopy appointments, undertake education and raise awareness through health promotion events, follow-up women who DNA. We have funded a smear taker so that we can provide smears for women at more convenient locations and at priority screening days. More emphasis has been placed on Māori, Pacific and Asian women over the last year. As with Breast Screening we work with Primary Health Organisations, General Practices, Māori and Pacific Providers (Mana Wahine Alliance and the Central Pacific Collective). We have subcontracts with Maraeroa Marae Health Clinic and Te Runanganui o Te Atiawa ki te Upoko o te ika a Maui to support smear taking and support to screening.

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In 2018, the National Cervical Screening Programme (NCSP) is planning to change the first step in the screening pathway from liquid-based cytology screening to primary human papillomavirus (HPV) screening. Primary HPV screening means that a cervical screen sample is first tested for the presence of an HPV infection because almost all cervical cancer is caused by infection with HPV. High-risk types of HPV can cause cell changes in the cervix which, if not treated, can lead to cervical cancer. This will also decrease the screening interval from three to five years.

Also in 2018 we will also see an increase in the screening age from 20 years old currently to 25 years old (as well as self-sampling, which is currently being trialled in Northland and Auckland). The primary reason for the age increase is because HPV, which causes more than 90 per cent of cervical cancers, is common in younger age groups and typically clears up on its own.

2.3 Symptomatic Breast Services

Regional Screening Services also include the Hutt Symptomatic Breast Clinic and a Wairarapa Symptomatic Breast Clinic (contracted). Women who have a positive result from a screening mammogram are referred to a breast clinic as the final part of the screening process. Women with breast symptoms are also referred directly to this service. The symptomatic clinics are DHB hospital services and are a separate stream of both activities and funding. The symptomatic services were joined with screening around 10 years ago (they utilise the same process and staffing much of the time) to ensure that women had a seamless journey through their breast cancer pathway.

The symptomatic service involves assessment and diagnosis, surgical clinics and referral for surgery (via surgical services), follow up and surveillance and then referral back to the screening programme. High risk women are also monitored through the symptomatic service. The growth in this service over the last few years has been significant and as such is straining the clinical staff resources (radiologists, radiographers, surgeons and nurses).

3. WHERE ARE WE AT WITH BREAST AND CERVICAL SCREENING?

Breast Screen Central exceeded the 70% screening target for all women overall in 2016/17. While we did not meet these targets for the Pacific and Māori women in all geographical areas we continue to focus on these priority women to ensure their rate improve. We did continue to make incremental gains against this target for Māori and Pacific women in all three geographical areas (see Table 1).

BSC screened 29,396 women across the sub region in 16/17m which was 1,400 above the budgeted target of 28,000.

Saturday priority clinics for combined breast and cervical screening have proved very popular and successful in improving access for high-priority women. We hold these regularly over the year at Hutt hospital and Kenepuru hospital, and are hoping to be able to facilitate a Wellington-based one later this year.

The National Screening Unit has changed their screening websites with a new “Time to Screen” logo with different colours for cervical (orange red- see below) and breast (blue). The new website and resources along with a new ‘Facebook’ launch will allow women easier access to information.

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DHB coverage comparison trends by ethnicity

Table 1: BSA coverage (%) of women aged 50–69 years in the two years ending 31 March, 2015, 2016, 2017, by ethnicity and District Health Board

DHB Māori Pacific Other Mar 2015 Mar 2016 Mar 2017 Mar 2015 Mar 2016 Mar 2017 Mar 2015 Mar 2016 Mar 2017

Northland 69.2% 69.1% 70.3% 70.3% 64.1% 68.3% 71.5% 70.9% 72.7% Waitemata 64.7% 64.1% 63.6% 76.2% 75.2% 74.1% 67.6% 67.5% 66.3% Auckland 63.4% 60.2% 57.6% 76.1% 75.1% 72.7% 65.3% 63.6% 63.2% Counties Manukau 67.8% 65.2% 62.8% 79.5% 77.8% 75.1% 68.5% 67.9% 67.1% Waikato 58.1% 59.8% 57.8% 63.4% 62.9% 58.5% 69.4% 69.1% 68.5% Lakes 65.0% 61.6% 62.0% 47.8% 51.5% 64.4% 71.3% 69.1% 70.5% Bay of Plenty 59.1% 59.9% 59.7% 77.3% 70.8% 65.3% 71.0% 72.2% 70.0% Tairaw hiti 65.2% 66.2% 69.3% 54.9% 56.2% 64.4% 70.8% 71.7% 72.6% Taranaki 62.2% 61.3% 61.1% 58.1% 62.7% 62.4% 75.2% 75.3% 75.5% Haw ke's Bay 64.6% 67.4% 66.2% 67.3% 65.9% 66.1% 73.6% 74.2% 74.9% Whanganui 70.2% 71.8% 71.4% 71.1% 75.0% 70.5% 76.5% 78.5% 79.1% MidCentral 62.2% 64.4% 65.2% 68.7% 66.0% 66.3% 76.1% 77.0% 77.6% Hutt Valley 66.1% 65.7% 67.5% 66.3% 64.7% 68.8% 75.3% 74.1% 76.4% Capital and Coast 61.7% 65.5% 66.9% 62.7% 67.2% 69.2% 71.2% 72.8% 73.3% Wairarapa 65.1% 70.3% 69.1% 79.6% 81.4% 71.9% 73.2% 75.0% 76.3% Nelson Marlborough 75.2% 72.9% 77.3% 61.0% 64.8% 68.1% 78.7% 79.2% 80.5% West Coast 76.3% 70.5% 67.7% 36.8% 35.0% 30.0% 76.4% 77.7% 76.6% Canterbury 74.9% 71.5% 69.2% 65.0% 62.9% 64.0% 79.9% 78.6% 76.0% South Canterbury 73.7% 73.1% 70.9% 50.0% 56.7% 52.9% 79.2% 79.2% 78.0% Southern 66.2% 62.5% 64.8% 61.0% 56.5% 62.3% 74.3% 72.3% 75.0% Total 65.2% 64.8% 64.5% 74.2% 73.2% 71.9% 72.6% 72.1% 71.9%

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Table 2: Wairarapa BSC coverage in the two years until June 2017 by ethnicity.

Table 3: Capital and Coast BSC coverage in the two years until June 2017 by ethnicity.

Table 4: Hutt Valley BSC coverage in the two years until June 2017 by ethnicity.

4. NATIONAL CERVICAL SCREENING PROGRAMME DATA

The Cervical screening graphs show that while we achieved the 80% target for European/other women for C&CDHB (Table 2) we did not reach coverage for Māori and Asian women across all 3 DHBs. Pacific coverage was achieved for WDHB. For cervical screening, the Asian population are also proving more difficult to recruit to the programme with the exception of HVDHB which continues to improve. We continue to work with the PHOs and GP practices to identify, recruit and screen the hard to reach priority women. Targeted data matching with high-needs practices using PHO/Data Matching Reports to assist follow-up of DNA women, phoning overdue women on behalf of the Practice (day/evening), booking clinic appointments, arranging transport and support, referral to support to services and re-engagement to

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priority Saturday Smear Clinics are a key contributor to increasing coverage and reducing inequalities for cervical screening.

Recently the National Cervical Screening Programme Support to Services Providers was given access to the NCSP Register for screening histories. This will be particularly useful for after hour’s clinics and to answer queries from women preventing delays to screening.

4.1 NCSP coverage comparison trends by ethnicity

Table 5: NCSP coverage (%) of women aged 25–69 years in the three years ending 30 June, 2015, 2016, 2017, by ethnicity and District Health Board

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Figure 1: Overall NCSP coverage (%) of women aged 25–69 years in the three years ending 30 June 2017 by District Health Board

Coverage (%) 100 90 Target coverage 80% 80 70 60 50 40 30 20 10 0 i i l i l t t t y y s t y y a n d d o u t a h i k s s t a u a t r t r r t e a a n n r u g p a h a n n a a t u u a e k o k a a u a B n H l l e k o o a n b b w

r h l i a u m o T r r t k a h g s e a r a C C a L n r t e P e e u r

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*For the total population the number of additional screens is the number required to move from the total population coverage to 80%. This may not be the same as the sum of additional screens required for each ethnic group to reach 80%.

Figure 1: NCSP coverage (%) of women aged 25–69 years in the three years ending 30 June 2017 by ethnicity, Total Coverage

Coverage (%) Jun 2015 Jun 2016 Jun 2017 100 90 Target coverage 80% 80 70 60 50 40 30 20 10 0 Māori Pacific Asian Other Total Ethnicity

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Figure 3: NCSP coverage (%) of Māori women aged 25–69 years in the three years ending 30 June 2017 by District Health Board

Coverage (%) 100 90 Target coverage 80% 80 70 60 50 40 30 20 10 0 i i i l l t t t y s y t y y n a d o a d u t h i k t s a s u a t r t r r e t a a g n n r u p a h n a a n t a a u u e k o k a a a u B n H o o l l e k a n b b r w

h l i a u m o T r t r k a h g s e r a a C C L a r n t P e e e u r c r

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Figure 4: NCSP coverage (%) of Pacific women aged 25–69 years in the three years ending 30 June 2017 by District Health Board

Coverage (%) 100 90 Target coverage 80% 80 70 60 50 40 30 20 10 0 l i i i l t t t y s t y y y a n d d h o t a u i k s t s u a a r t t r r e t a n a g u p r n a h a n a n a t u a u e k o k a a u a B n n H l o e k o l a n b b w r

h l i a u m o T r r t o a k h g e s r a a C C a L r n t P e e e u s r c

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Figure 5: NCSP coverage (%) of Asian women aged 25–69 years in the three years ending 30 June 2017 by District Health Board

Coverage (%) 100 90 Target coverage 80% 80 70 60 50 40 30 20 10 0 i i i l l t t t y s t y y y a n d d o t a u h i k t u s s a a r t t r r e t a n a g n r u p h a n a a n a t u a u e k o k a u a a B n H l k o o e l a n b b w r

h l a i u m T o r r t k a h g s e r a a C C L a r n t P e e e u r c

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5. WHAT ARE WE DOING TO ADDRESS EQUITY ISSUES?

Addressing equity is a significant part of the work that both the cervical and the breast screening Recruitment and Retention (R&R, also known as ‘health promotion’ or ‘invitation and recall’) teams do. A higher proportion of priority women (Māori and Pacific) than non-Māori/non-Pacific are not enrolled with their GP or do not have a GP. Evidence shows that some Māori and Pacific women respond positively to direct approaches by phone or face-to-face rather than mail and that it is important for us to provide appointments at places and times convenient to people in lower paid jobs, who have less flexibility in their work and may be using public transport as well.

The service and the R&R teams have to find, engage and get these women to screening. There are a number of ways they do this: ∑ Data matching with primary care practices identifies women who are not registered and provides permission for BSC, on behalf of the practice, to contact the women to enrol them in the programme. ∑ We are trialling a new approach to primary engagement with priority women by phoning directly rather than sending out invitation letters and waiting for a response. This avoids inevitable waiting to discover that a woman has moved or does not respond to invitation or official looking letters, and allows immediate engagement and opportunity to address any concerns the women may have. ∑ We are training staff to have a better understanding of what equality and equity so they can get a better perspective on what they need to do to support priority women. ∑ We hold Saturday priority combined screening clinics at both Hutt and Kenepuru base sites. Our R&R team and our primary care partners can transport these women if required. ∑ We are planning Hutt and CCDHB staff combined cervical and breast priority days. ∑ We are reviewing how and where we deliver breast screening (fixed sites versus mobile) to ensure that we provide the best opportunity for priority women to access screening.

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∑ When we contact priority women we are asking them what the issues are that prevent them from accessing our services. ∑ Engaging with Māori and Pacifica through DHB Māori and Pacific Units, Mana Wahine, and Central Pacific Collective ∑ We have subcontracts with Maraeroa Marae Health Clinic and Te Runanganui o Te Atiawa ki te Upoko o te ika a Maui (via Puketapu Kokiri Centre) to run cervical screening clinics. These are not associated with the women’s GPs so there is no charge and no stigma about attending when there are unpaid bills owing.

Hutt Valley District Health Board Page 10 [Month Year]

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CPHAC-DSAC INFORMATION PAPER

Date: 3 November 2017

Helene Carbonatto, GM Strategy, Planning & Outcomes, Hutt Valley DHB Author Nigel Broom, Executive Leader, Planning & Performance, Waiarapa DHB

Ashley Bloomfield, CE Hutt Valley DHB Endorsed by Adri Isbister, CE Wairarapa DHB

Subject Update on the bowel cancer screening programme

RECOMMENDATION It is recommended that the CPHAC-DSAC Committee: 1. Notes the approach to implementation of the bowel cancer screening programme in the Hutt Valley and Wairarapa districts; 2. Notes the equity approach that is in place across Hutt and Wairarapa DHBs.

1. Introduction Bowel Cancer is the most frequently diagnosed cancer and the second highest cause of cancer death in New Zealand. More than 3000 people are diagnosed with bowel cancer every year and more than 1200 die from the disease. (MOH) The incidence of bowel cancer among Māori is lower than for other ethnic groups, however the mortality rate is relatively high. In 2010, the Ministry of Health (‘the Ministry’) awarded the Waitemata DHB a contract to plan and implement a four-year bowel screening pilot. The main aim of the pilot was to establish if a national bowel screening programme was feasible in New Zealand. Launched in October 2011, the pilot has been operating at full capacity since January 2012. Following the Pilot, Ministry announced the roll out of a National Bowel Screening Programme (NBSP), with Hutt Valley and Wairarapa being the first DHBs to commence in July 2017.

2. Implementing the bowel screening programme

Hutt Valley Since the ‘Go live’ date in July 2017, there have been just under 2800 invitations sent to Hutt residents to participate. Of the returned kits, there have been approximately 900 negative tests, 45 tests that have not been able to been analysed, and 53 tests returned positive for blood. Of the 53 positive results, we have a number of referrals at different stages of the patient pathway, with some opting for private care. The endoscopy services has now completed several procedure lists with one patient found to have cancer, and one patient undergoing further investigations for suspected cancer. All systems and processes for patient care are embedded and all ‘teething’ issues have been. We continue to develop the range of reports and plans required by the Ministry and there is ongoing community and stakeholder engagement to raise awareness of the Programme.

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Wairarapa In Wairarapa, approximately 90 – 95 kits are sent weekly to eligible participants, with a total of 1,300 sent up until the end of October with 493 returned. It is too early to interpret the data, however early indications of August’s data show good participation rates. There have been 38 spoilt kits returned, and these are monitored to determine if any change in education or local messaging needs to occur. All patients with positive results have either undergone or are booked for colonoscopy. We are currently embedding the systems and processes developed to meet the programme requirements and for stakeholders in the pathway. Quarterly reporting and review by the MOH will be undertaken during the initial rollout phase. An increase in symptomatic referrals is currently being experienced, and this is being monitored to determine if it is a short term consequence of increasing community awareness or is an ongoing trend.

2.1. Equity Approach Ensuring equitable participation has been a key focus of the programme to date. The key tasks were to identify our populations, establish priority groups, outline activities already in the pathway, and undertake engagement and consultation. As there were no previous participation data for Hutt Valley and Wairarapa DHBs, and it had been identified in the Pilot there were lower participation rates for Pacific and Māori, we have focused our approach on these populations. This is also consistent with the nationally identified priority groups of Māori and Pacific peoples.

2.2. Participant information/Resources Written information for participants is available in multiple formats and languages, including videos, posters, website, and leaflets. There is a 0800 number for participant queries about the Programme, with people who speak a range of languages available to speak with callers. There has been a collaborative approach between Waitemata, Hutt Valley and Wairarapa DHBs and the Ministry to review existing resources as we moved from the pilot to a national programme.

2.3. Active Follow Up Waitemata provides an Active Follow Up process for people who do not respond at the invitation phase or return a test kit with a focus on the national priority populations of Māori, Pacific and Deprivation Quintile 9 and 10.

2.4. Providing followup When there is a positive FIT (result), and subsequent referral/notification from Primary Care, DHBs have systems and processes to manage the care for the person. These range from nurse contact, interpreters, travel assistance, appointment reminders, DNA processes and contacts, and referral to Pacific or Māori Health teams as appropriate.

2.5. Primary Health Care Engagement occurred early with PHOs and primary care was involved from the outset. The PHOs in Hutt and Wairarapa have also participated in a series of equity forums alongside Māori and Pacific health providers and services. Four CME sessions have been held within the wider region covering Hutt, Wairarapa and Wellington GPs. These sessions are also open across the region, so can be attended any health professional or worked at a practice – GPs, Nurses, Health Workers, practice managers, receptionists, etc – in order to increase knowledge about the Bowel Screening Programme.

2.6. Pacific People’s Health Tofa Suafole-Gush has been a driving force in providing leadership and direction for the programme team. There has been a strategic approach at both DHBs to focus on engagement by Pacific groups. Work has also commenced engaging with Pacific Health workers to identify opportunities to reach Pacific communities and with Church Leaders on what bowel cancer is and why screening is important in the early detection of cancer. These presentations have been fronted by the Programme Clinical Lead, or Lead GP, across a range of

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community sites, supported from the pacific nurses and health workers and translated to the specific audiences. Pacific Health Nurses are championing the programme at any opportunity and have been provided tools such as the Powerpoint presentation and flyers to enable this. Development of Pacific specific tools is essential to remaining engagement and we are looking forward to receiving translations of resources from the Ministry. Pacific radio interviews are also being planned, translated into five pacific languages, as well as ‘quick snippet’ sections on a daily basis, e.g. don’t forget to return you BSP kit if you received one; don’t forget your hospital appointment, etc. As the eligible Pacific population is relatively small in the Wairarapa region individual participant approaches are possible. At each engagement opportunity we are reviewing feedback and developing the approaches as we learn.

2.7. Māori Health Engagement and consultation with the Māori Health Teams at both sites has been initiated. The Hutt Māori Health team manager and a lead staff member have facilitated links with community-based Māori Health Services and supported attendance and engagement by the programme staff, which has now led to further engagement opportunities. Alongside individual engagement, we recently held a forum at Hutt DHB focused on ensuring equitable participation in the programme.. This included representatives from Te Awakairangi PHO, Pacific People’s Health (HVDHB), Pacific Health Services, Compass Health PHO, MOH, Māori Health Unit (HVDHB), Kokiri-Hauora services, and Te Runanganui. Actions and outcomes from the meeting are being followed up. The Wairarapa Maori Health Directorate is very involved in the Wairarapa Bowel Screening Programme. From early on in the programme an Equity Advisory Group was established with representation from Primary Health, PHO, Maori Health, Pacific, Disability and the BSP Clinical Lead and Nurse Co-ordinator. This group meets regularly and lead equity planning. This has also provided the opportunity to meet with different teams and establish contacts within services. The Kaumatua Council have agreed to champion the campaign on behalf of the wider Maori community. The Maori Health Co-ordinator and BSP Clinical Nurse Co-ordinator have been presenting to a number of community groups on bowel screening.

3. Bowel Screening Regional Centre (BSRC) Hutt Valley DHB hosts the BSRC for the Central Region. A regional forum was held for stakeholders from the six DHBs, the Central Cancer Network, Primary care, Screening and MOH, with excellent attendance and feedback. There was presentation from Hutt Vally and Wairarapa DHBs and the Ministry, starting the processes of shared learnings and knowledge. Key topics of discussion were equity, financial information, volumes and what information would be provided to help DHBs plan. Hawke’s Bay DHB has been given a go-live date of October 2018. The remaining Central Region DHBs (Whanganui, MidCentral and Capital & Coast) have not yet been told when bowel screening will commence in their areas although all DHBs will be signing a two-phase contract within the next month. Phase one asks DHBs to provide information for the Ministry’s 2018/2019 business case, with the second phase covering planning and implementation of bowel screening. The Central Region BSRC has also successfully bid to host the National Pacific Bowel Screening Network. Negotiations are now in place regarding what services will be provided under this umbrella and the Network’s first Fono will be held on 4 December.

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PUBLIC

DISCUSSION PAPER

13 November 2017

Author Dr Pauline Boyles, Director of Disability

From: Rachel Haggerty: Director Strategy Innovation and Performance Helene Carbonatto: Director Strategy planning and outcomes Nigel Broom: Director Planning and Performance

Endorsed By Debbie Chin: Chief Executive Capital and Coast DHB Ashley Bloomfield, Chief Executive, Hutt Valley DHB Adri Isbister: Chief Executive, Wairarapa DHB

Subject Disability Strategy Implementation First Quarter Report

RECOMMENDATIONS

It is recommended that Board members Note 1. Sub Regional Report key areas ß Dashboard of highlights (first quarter) against the sub regional Disability Strategy and 17/18 commitments (including annual plan) ß Formal agreement and Co- production of electronic health passport 17th October to 27th) currently occurring: (Ministry of Health, Health and Disability Commissioner and Sub Regional District Health Boards) ß New Zealand Medical Journal has accepted article for publication (experiences of deaf people within health services).

2. Local Area Highlights ∑ Wairarapa DHB ∑ Hutt Valley DHB ∑ Capital and Coast DHB

3. SRDAG Engagement and activities 4 Special tribute to Debbie Chin

APPENDIX ONE: DISABILITY STRATEGY HIGHLIGHTS DASHBOARD FIRST QUARTER AND 17/18 TARGETS

APPENDIX TWO: ACCESS MAP WAIRARAPA DHB

1. PURPOSE 1.1 To present the Disability Strategy implementation monitoring framework against Sub Regional Disability Strategy (2017-22) 1.2 To present first quarter highlights of progress and achievements against sub regional strategic framework

1.3 To present recent progress updates on improving clinical and service responsiveness Wairarapa Hutt Valley and Capital and Coast DHBs

Wairarapa, Hutt Valley and Capital & Coast District Health Board

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PUBLIC 1.4 To report Sub Regional Disability Advisory Group activity

2. PERFORMANCE FRAMEWORK: SUB REGIONAL DISABILITY STRATEGY (2017-22) The Sub Regional Disability Strategy was endorsed by the three District Health Boards in April 2017 and publically launched June 9 2017. The performance framework presented shows how this ambitious plan will begin and gradually unfold with annual developmental targets. The following summary will target two key strategic areas: the monitoring framework and the development of electronic resources. 2.1 Performance Framework and Structural Measures Progress under the following two focus areas are described as progress highlights

Focus Area 1: Leadership: The sub-regional DHBs, in partnership with disabled people, their families, Whanau and communities; plus, other relevant stakeholders, will provide leadership to achieve equity in health and wellbeing on an equal basis to others.

1.4 Ensure better accountability by creating a monitoring framework

The strategic framework was produced after significant intersectoral consultation by a sub committee of SRDAG with the Disability Strategy team. The 72 actions underpinning the main areas are documented and tracked within the wider framework. The front page highlights dashboard measures activity and early progress against each key focus area.

This framework represents the most rigorous form of monitoring available nationally available within District Health Boards. It identifies progress and quality indicators yielding some contributory measures to overall service improvement.

The monitoring of improvement on disability access using structural/system measures remains problematic in health services. The lack of a consistent national and international data set that is agreed across all services is demonstrated by the lack of disability population analysis in each published health needs assessment report. Therefore a key deliverable of this strategy of interest nationally is the overall methodology including data collection using disability alerts. In total 9000 people now have registered disability alerts across CCDHB and Hutt valley SIP analyst team, two consumer/clinical members of SRDAG and Disability Strategy and Performance have formed an expert monitoring group to meet the requirements of strategic area 1.4.

Focus Area 2: Inclusion and Support The sub-regional DHBs will improve and promote the full inclusion of disabled people and will ensure the best service for disabled people and their families is available on an equitable basis

2.2 Co- production of electronic health passport Ministry of Health, Health and Disability Commissioner and Sub Regional DHBs (Appendix Two)

This project relates to the following strategic areas:

1.1 Encourage intersectoral leadership on disability issues across government organisations and community and public Health Services to Partner Work with local communities

1.2 Practice positive partnerships to enhance collaboration and co-design

2.2 Ensure IT platforms accommodate disability responsiveness tools

See Appendix one for highlight dashboard.

Wairarapa, Hutt Valley and Capital & Coast District Health Board

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PUBLIC The sustained commitment by all sub regional DHBs to the health passport since 2011 has resulted finally in a significant milestone agreement with the Health and Disability Commissioner and the Ministry of Health to refresh and develop an electronic version of the health passport. The leadership of Bob Francis is recognized in this report as pivotal to gaining funding from the Ministry of Health for the first stage development. This piece of work has been led by the members of the Sub Regional Disability Advisory Group alongside local area allies. Members led by Bob Francis have been generous with their time and expertise despite other significant commitments. Considerable work has been done with the group and the Disability Strategy team to achieve alliances with consumers and clinicians and identify testing environments and opportunities. At least 50 people from a variety of skill areas and experiences are engaged in the workshops and work place interviews.

Co Design and Sprint workshops

Educating each other: People with disability expertise collaborate with IT experts and clinicians

Wairarapa, Hutt Valley and Capital & Coast District Health Board

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PUBLIC

Key outputs: Four concepts which informed the proposition design: ∑ Modularity of information and the idea of tiers of information ∑ The possibility of integration with doctors systems ∑ The idea of visual triggers. ∑ The potential for Manage my Health to be used as one of the platforms

A proposition for experience design has been presented and has been critiqued. Negotiation with the Ministry of Health and the Director General for further funding for the next stage will occur within the next few weeks supported by the Health and Disability Commissioner

2.3 New Zealand Sign Language Plan

Focus Area 3: Access Services are more accessible and meet the health, wellbeing and social needs of disabled people, their families and Whanau.

3.4 Improve access to New Zealand Sign Language interpreters and quality of care for Deaf community

Progress on electronic resource development (MSD funded) is on track developed with support and advice from a sub regional deaf task force group. It is expected the resources will be launched early 2018. An article documenting research which took place in 2015 on the experiences of deaf people within health services has been accepted for publication by the New Zealand Medical Journal. It is expected to be released by the end of the year. Co- writers are Jo Witko, Dr Pauline Boyles, Dr Kirsten Smiler (Post doctoral fellow) and Rachel McKee (Victoria University post doctoral fellow). This work is unique in New Zealand and is expected to attract considerable attention from media. An important outcome is the commitment that has now been made by Strategy Innovation and Performance and the Disability Strategy Team to a long term plan to improve access for deaf NZSL users. The plan also aims to benefit people who are also hard of hearing.

3. LOCAL AREA INITIATIVES 3.1 Wairarapa DHB

Highlights ∑ International day of persons with disability planning underway – hospital display, afternoon tea, awaiting 3DHB plan and materials for implementation ∑ Executive Leadership Team agreed establishment of a strategic Disability Action Group staff. This group comprises of staff from hospital and community in collaboration with consumer

Wairarapa, Hutt Valley and Capital & Coast District Health Board

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PUBLIC advisory groups. It is led by The Chief Medical Officer and the Director of Disability Strategy and Performance and the first meeting will be held in February 2018 ∑ The Executive Leadership Team agreed that e learning would be mandatory from 2018 for patient facing staff. This is a first step to more comprehensive work force development ∑ ELearning rollout in Wairarapa is underway – communications, education of lead staff in clinical areas concurrently and two competitions to start this week with prizes to be presented at Staff Xmas party. ∑ Accessible route (CCS) managed assessment done last week. Identified some actions required Appendix Two both in hospital grounds and outside. This has been a useful exercise to engage younger volunteers who have experience of disability and improve access for all.

3.2 Hutt Valley DHB Highlights ß Work force Development: a number of training sessions have occurred with allied health, nurses and Year one doctors over the last month. These have been well received and follow up ß Work force development: Primary Care disability responsiveness training is developed and run with SRDAG members and staff of the DHB and PHO ß Improved on site access to information and support for staff and people using services. Extended use of main corridor help desk. Volunteer support (associate member of SRDAG) has led to a fully operational help desk three days per week. This facility will be developed for a range of information and navigation tools as they are developed ß Healthy Ageing Expo attracts significant engagement from community on use of health passport and alerts registration. 47 people registered for alerts and will be followed up by staff to ensure their support needs are accurately documented within the clinical record through the disability alert ß Final co design Hui for the child to adult transition pathway within primary care has lead to a proposal for an electronic version of the family developed toolkit. This will be tested by families with primary care Hutt Valley (Hutt Valley demonstration for sub regional use). See Appendix One 2.2

3.3 CAPITAL AND COAST DHB HIGHLIGHTS Highlights ∑ Work force Development: a review of work force needs with regard to disability competence as per the sub regional plan is big undertaken. Education sessions are being co led by consumers and staff across a range of disciplines with excellent evaluations. ∑ Interim Clinical Governance (ICG) 1 is leading to timely decisions between and by needs assessment services. Seven patients were referred via the Disability Strategy team during September. Each referral was accepted but also referred on to the relevant agency which created immediate transparent and timely responses prior to the date of the panel indicating improved communications and responsiveness. ∑ Engagement in Health Consumer Council’s Annual Meeting. ∑ Whole of Life Strategic project on development of an integrated approach to needs assessment service delivery is progressing well with excellent cross systems engagement from community and hospital services. ∑ SRDAG involvement in Citizen’s Health Council development has been endorsed and supported by the group ∑ Citizen’s Health Council follow up workshop with all partners 27 October

1 ICG was established to address the needs of complex patients for whom clinicians struggled to discharge and/or place in the community due to the funding silos between age groups and diagnoses Wairarapa, Hutt Valley and Capital & Coast District Health Board

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PUBLIC 4. SUB REGIONAL DISABILITY ADVISORY GROUP UPDATE

KEY ACTIVITIES The group has been actively engaged in the co production of the health passport design as well as a range of local and national development areas.

The following areas of activity were reported at the last meeting 29th September 2017:

∑ People First member input and presentations on Health Passport to regional members ∑ Wairarapa and Hutt Valley Healthy Ageing Expos successful Staff and community driven ∑ MOH Health and Disability Workforce Strategy, Consumer Working Group, 11 August. ∑ Engagement with Ministry of Health on Electronic record ∑ Nursing Workforce Taskforce, meeting 25 August. Consumer representation from sub regional members ∑ IHC Public Meeting on Enabling Good Lives (EGL), 29 August, St Joseph’s Church: report on Enabling Good Lives and Disability Support System Transformation demonstration (Mid Central) ∑ MOH NZ Health Strategy road show, half day 6 Sept, Pipitea Marae ∑ IHC/ DPA Election Forum, 7 Sept, ASB Arena, Kilbirnie.

Significant work is being done by each member in their local area as well as in raising the profile of disability and health within a range of other forums. This includes election forums, health forums and multiple workshops on Disability Support System transformation. Their ownership of and engagement with the work within each DHB and the Disability Strategy team is invaluable and much appreciated. Special thanks to Bob Francis for his leadership and determination particularly in the achievement of funding for the important project to review and re develop the national health passport

5. TRIBUTE TO DEBBIE CHIN The disability community wish to pay tribute to the work and tenacity of Debbie Chin Chief Executive CCDHB. She has not only supported the work of CPHAC DSAC, the Sub Regional Group and the teams involved, she has recognized and valued the leading and cutting edge nature of the work being undertaken. Without this leadership from the CEO the work would not have flourished. SRDAG and the Disability Strategy Team are unanimous in their appreciation and admiration for Debbie Chin. We wish her well in her future endeavours

Wairarapa, Hutt Valley and Capital & Coast District Health Board

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Review of the Footpath Accessible Journey

Masterton Hospital Te Ore Ore Rd, Lansdowne, Masterton 5810

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Assessment of accessibility and usability for people with impairments

October 2017

Description of the Journey

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Te Ore Ore Road exiting from the entrance to the Hospital, tuning right to nearest pedestrian crossing and returning to nearest pedestrian crossing to the left of the Hospital. Through Blair St, across the swing bridge into Queen Elizabeth Park and return. The review was completed during daylight hours on a fine day. No comment has been recorded on shelter or lighting.

Participants. Bridget McLaren Matt Wills Hemi Veale Heather Atkinson, Disability Responsiveness Advisor WRDHB

Overview. Generally the footpaths adjacent to the main roads were in good repair and of excellent width. Foliage from trees and gardens did not impact on the journey which was in the main manageable by all participants. Blair Street, however lacked footpaths and the journey was completed in the road access.

Feature Description / Issues Car Park outside A total of 4 mobility car parks, with worn paint and no main entrance signage. No kerb cut to footpath, access via road. Refer to Building Code 4121:2001 Section 5 Car Parks.

Recommendation: Directory board less than 1000mm from kerb raked 6º from vertical and max height 1750mm. Accessible park is visible from vehicle entrance to car park. If not, directional signage is provided to indicate location of car park. Identified by ISA on ground, wall or post. ∑ To increase visibility and help reduce the level of abuse by non-disabled drivers, place the ISA painted yellow within a blue square located at the

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entry end of the mobility park.

∑ Posts displaying the ISA also help identify the location of car parks. NB. Their position can impede exit from rear mounted hoist vehicles if they are backed into the car park for safety. Placing the ISA on a convenient wall, or placing posts further back from the car park helps overcome this problem. Note: There is no time limit on parking in Hospital grounds.

Hospital Dairy. The footpath has advertising boards along the footpath close to the dairy car park and on the kerb. This restricts a clear vision or tapping line for people with vision impairments.

Recommendation: Owner of the diary be requested to keep all signs on one edge of the footpath. Masterton Council By Law 4.2b states you shall not: “Place or leave any material, good, or thing, including signage, on a public place that could obstruct the public right of passage, without the permission of an authorised officer and then only in accordance with such conditions as may be imposed”

Montgomery Kerb cut on eastern side has potential for wheelchairs to Crescent get stuck. Road has been resurfaced leaving a ditch rather than a smooth transition and no variation of slope from side to side. Any lip slows down the ability of users

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of mobility equipment to quickly exit the road and hence reduce possible interaction with vehicles. The participant using a power chair was able to increase speed to negotiate the uneven surface, with the risk of tipping the chair.

Lake view crossing The South side has an uneven transition causing the manual wheel chair user to hit the foot plates on the road surface.

Entrance to Hospital Signage for the entrance to the hospital has very limited car park. visibility from either direction along Te Ore Ore Road. It is unclear where pedestrians should enter the Hospital grounds.

Recommendation: Directional road signage to the Hospital be considered at major intersections along the accessible journey and at entry points to Hospital grounds.

See table on signs at end of report.

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Blair Street The crossing has tactile tiles installed. One panel is not aligned correctly to the direction of travel and would lead people to the raised island in the centre of the crossing. Tactile ground surface indicators (TGSI) provide pedestrians with visual and sensory information. The two types of TGSI are warning indicators and directional indicators. Warning indicators alert pedestrians to hazards in the continuous accessible path of travel, indicating that they should stop to determine the nature of the hazard before proceeding further. They do not indicate what the hazard will be. Directional indicators give directional orientation to people who are blind or have low vision and designate the continuous accessible path of travel when other tactile or environmental cues are insufficient. For further information see RTS 14 – Guidelines for facilities for blind and vision impaired pedestrians

The bus stop, visible from Blair Street, in the hospital grounds is not accessible, although it does provide shelter.

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There are no footpaths on either side of Blair Street. Pedestrians have access only along the road. There are many barriers through to the medical centre. These include 2 speed bumps, cones blocking access to the flat roadside, vehicles parked on yellow painted, no stopping lines and broken glass on roadside.

One mobility car park outside the CSISB required repainting and appropriate signage

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DHB mobility car parks close by the Selina Hospital were all occupied but no vehicles were displaying mobility parking permits.

Signage of mobility car parks outside of the Medical Centre is appropriate but outdated.

Note. The emergency assembly area is not accessible. Recommended: A review of assembly points be undertaken to ensure they are accessible and the Emergency Response Plan be amended if appropriate.

Access to Queen The walk over the swing bridge into Queen Elizabeth Elizabeth Park. Park was completed with one of the group pushing the manual wheelchair. The route was not accessible but could be a feature to be developed by Council in future. This would require the ramp leading up to the bridge to be longer and have a stable, firm, slip resistant flat surface under all environmental conditions.

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Once across the bridge access to Dixon Street was on the road.

SIGNS (NZBC D1.1[c], D1.3.6[c], F8.1[c], F8.2[d], F8.3.4, G5.3.6; D1/AS1 1.1.1, F8/AS1 5.0; NZS 4121 4.8 and Appendix E)

The Building Act 2004, the Building Code and NZS 4121:2001 all require the erection and maintenance of appropriate signs both inside and outside a building to be : ∑ Informative - advising about availability of facility or service ∑ Directional - directing to a specific facility ∑ Locational - identifying the place where the facility is provided

The two signs required to be displayed are the : ∑ International Symbol of Access (ISA) ∑ International Symbol of Deafness (ISD)

For additional detail on signs refer to ‘Accessible signage guidelines’, Blind Foundation 2013. https://bf-website-uploads-production.s3.amazonaws.com/uploads/2015/09/Accessible-Signage-Guidelines.pdf

General: Are both the ISA and the ISD displayed with the correct proportional layout, lettering and colour contrast? Are signs fixed 1400 - 1700mm above floor or ground level to bottom of sign plate? Car parking: Is the ISA marked on the surface finish of the accessible car parking space(s) provided? If necessary, is ISA also displayed on wall or post? If necessary, is the ISA displayed to indicate direction to accessible entrance? Entrance: If necessary, is the ISA displayed to indicate an alternative accessible entrance?

Accessible routes: If necessary are ISA signs displayed to indicate direction to lifts and accessible toilets? On main information board in entry foyer, is the ISA displayed to indicate location of accessible toilets? On main information board in entry foyer, is the ISD displayed to indicate location of any listening systems installed? Also refer to ‘Listening Systems’

Doors: Is the ISA displayed on the entry door(s) to all accessible toilets? Is the ISA displayed on the entry door(s) to all accessible showers? Is the ISD displayed on the entry door to any room which has a listening system installed? Also refer to Listening systems" earlier in the checklist

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Raewyn Hailes Regional MAC Coordinator (Moving Around Communities) for the Central Region. CCS Disability Action Wellington P O Box 35156, Naenae, Lower Hutt, 5041

DDI: 04 5678913 Mob: 027 6003828 EML: [email protected] www. ccsDisabilityAction.org.nz

Te hunga hauā mauri mō ngā tāngata katoa

89 CPHAC_DSAC Committee Papers 17 November 2017 - 4. APPENDICES

Bee Healthy Dental Service - WHOLE SERVICE Monthly Balanced Scorecard September 2017 KEY PERFORMANCE INDICATORS 2016/2017

Sep-17 Period Sep-17 Period PATIENT EXPERIENCE PROCESS & EFFICIENCY Target Month Target YTD Target Month Target YTD Number of preschool children enrolled 27178 24193 Did not attend rate (excludes:Mobile) 15% 15% 15% 16% Total % Preschool children enrolled 95% 89% DNA rate Primary 15% 15% 15% 15% Total number of preschool 2-4 yr olds enrolled 16172 DNA rate Maori Primary 15% 26% 15% 25% Target Month Target YTD DNA rate Pacific Primary 15% 27% 15% 28% Total number of primary school children enrolled 47691 DNA rate Other Primary 15% 9% 15% 10% Number of Primary school examinations 4883 4551 34187 32844 Primary school examinations % 93% 96% DNA rate Pre School 15% 17% 15% 18% Number of Fluoride Varnish Applications 3889 27642 DNA rate Maori Pre School 15% 28% 15% 30% Fluoride Varnish % 85% 84% DNA rate Pacific Pre School 15% 35% 15% 34% DNA rate Other Pre School 15% 10% 15% 13%

Number of Preschool examinations 1897 905 13191 7889 Bitewings % 42% Preschool examinations % 48% 60% Number of Fluoride Varnish 443 3527 Fluoride Varnish % 49% 45%

Enrollment Traffic Lights DNA Traffic Lights Traffic Light Rules Colour Code Traffic Light Rules Colour Code 90%-100% >=15% 70%-89% 16%-24% 0-69% <=25%

Examinations & Completions Traffic Lights Traffic Light Rules Colour Code 95%-100% 80%-94% 0-79%

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Bee Healthy Dental Service - HVDHB Monthly Balanced Scorecard September 2017

KEY PERFORMANCE INDICATORS 2016/2017

Sep-17 Period Sep-17 Period PATIENT EXPERIENCE PROCESS & EFFICIENCY Target Month Target YTD Target Month Target YTD Number of preschool children enrolled 9428 8491 Did not attend rate (excludes:Mobile) 15% 16% 15% 18% Total % Preschool children enrolled 95% 90% DNA rate Primary 15% 15% 15% 17% Total number of preschool 2-4 yr olds enrolled 5675 DNA rate Maori Primary 15% 24% 15% 26% Target Month Target YTD DNA rate Pacific Primary 15% 24% 15% 26% Total number of primary school children enrolled 17057 DNA rate Other Primary 15% 9% 15% 11% Number of Primary school examinations 1764 1557 12351 11971 Primary school examinations % 88% 97% DNA rate Pre School 15% 20% 15% 19% Number of Fluoride Varnish 1530 11447 DNA rate Maori Pre School 15% 31% 15% 30% Fluoride Varnish % 98% 96% DNA rate Pacific Pre School 15% 39% 15% 33% DNA rate Other Pre School 15% 11% 15% 12%

Number of Preschool examinations 672 375 4619 3008 Bitewings % 47% Preschool examinations % 56% 65% Number of Fluoride Varnish 240 1689 Fluoride Varnish % 64% 56%

Enrollment Traffic Lights DNA Traffic Lights Traffic Light Rules Colour Code Traffic Light Rules Colour Code 90%-100% >=15% 70%-89% 16%-24% 0-69% <=25%

Examinations & Completions Traffic Lights Traffic Light Rules Colour Code 95%-100% 80%-94% 0-79%

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Bee Healthy Dental Service - CCDHB Monthly Balanced Scorecard September 2017

KEY PERFORMANCE INDICATORS 2016/2017

Sep-17 Period Sep-17 Period PATIENT EXPERIENCE PROCESS & EFFICIENCY Target Month Target YTD Target Month Target YTD Number of preschool children enrolled 17749 15703 Did not attend rate (excludes:Mobile) 15% 14% 15% 15% Total % Preschool children enrolled 95% 88% DNA rate Primary 15% 15% 15% 14% Total number of preschool 2-4 yr olds enrolled 10497 DNA rate Maori Primary 15% 28% 15% 25% Target Month Target YTD DNA rate Pacific Primary 15% 29% 15% 29% Total number of primary school children enrolled 30634 DNA rate Other Primary 15% 9% 15% 9% Number of Primary school examinations 3119 2994 21836 20873 Primary school examinations % 96% 96% DNA rate Pre School 15% 14% 15% 18% Number of Fluoride Varnish 2359 16194 DNA rate Maori Pre School 15% 24% 15% 31% Fluoride Varnish % 79% 78% DNA rate Pacific Pre School 15% 30% 15% 35% DNA rate Other Pre School 15% 10% 15% 13%

Number of Preschool examinations 1225 530 8572 4881 Bitewings % 38% Preschool examinations % 43% 57% Number of Fluoride Varnish 203 1837 Fluoride Varnish % 38% 38%

Enrollment Traffic Lights DNA Traffic Lights Traffic Light Rules Colour Code Traffic Light Rules Colour Code 90%-100% >=15% 70%-89% 16%-24% 0-69% <=25%

Examinations & Completions Traffic Lights Traffic Light Rules Colour Code 95%-100% 80%-94% 0-79%

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Capital & Coast Select your DHB from the list in this cell #VALUE!

Number of Number of Mean DMFT for children with caries Number of Number of Decayed, Number of Teeth Number of Children Children Missing due % Caries Free Mean d Mean m Mean f Mean dmft Decayed Teeth Missing due Filled Teeth Examined Caries-Free to caries and to Caries Filled Teeth Dental Health Status Mean d Mean m Mean f Mean dmft All 5-year old Children 3,179 2,114 2,322 507 1,363 4,192 66% 0.73 0.16 0.43 1.32 2.18 0.48 1.28 3.94 All Maori 5-year old Children 429 216 487 119 272 878 50% 1.14 0.28 0.63 2.05 2.29 0.56 1.28 4.12 All Pacific 5-year old Children 348 137 565 180 307 1,052 39% 1.62 0.52 0.88 3.02 2.68 0.85 1.45 4.99 All "Other" 5-year old Children 2,402 1,761 1,270 208 784 2,262 73% 0.53 0.09 0.33 0.94 1.98 0.32 1.22 3.53 All Fluoridated 5-year old Children 3,131 2,081 2,294 505 1,345 4,144 66% 0.73 0.16 0.43 1.32 2.18 0.48 1.28 3.95 All Non-Fluoridated 5-year old Children 46 33 17 2 18 37 72% 0.37 0.04 0.39 0.80 1.31 0.15 1.38 2.85 Maori Fluoridated 5-year old Children 427 216 480 119 272 871 51% 1.12 0.28 0.64 2.04 2.27 0.56 1.29 4.13 Maori Non-fluoridated 5-year old Children 1 0 2 0 0 2 0% 2.00 0.00 0.00 2.00 2.00 0.00 0.00 2.00 Pacific Fluoridated 5-year old Children 347 137 564 180 303 1047 39% 1.63 0.52 0.87 3.02 2.69 0.86 1.44 4.99 Pacific Non-fluoridated 5-year old Children 1 0 1 0 4 5 0% 1.00 0.00 4.00 5.00 1.00 0.00 4.00 5.00 Other Fluoridated 5-year old Children 2,357 1,728 1,250 206 770 2226 73% 0.53 0.09 0.33 0.94 1.99 0.33 1.22 3.54 Other Non-fluoridated 5-year old Children 44 33 14 2 14 30 75% 0.32 0.05 0.32 0.68 1.27 0.18 1.27 2.73

Other comments dmft not recorded Enter any other comments here that may help explain the figures provided. Children Examined = 2 Caries Free = 0 dt=11 mt=0 ft=0 dmft=11 If any of these results did not meet your DHB's targets, From 2013 the % examinations on children 6 yearsand under associated with a set of PBW xrays has increased year on year from 19% in 2013 to 53% in 2016. you must provide an explanation here that includes a It would be expected that this would result in the detection of more dentine caries in this age group which may explain the 2-4% reduction in caries free. description of what your DHB is doing to rectify the problem.

C:\Users\SA-BB-~1\AppData\Local\Temp\BCL Technologies\easyPDF 7\@BCL@40049510\@[email protected] Page 1 of 1 Age 5 Printed on 11/13/2017 at 3:15 PM

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Healthy Ageing Strategy

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E noho ora ana te hunga pakeke, e noho pai ana i nga¯ tau o te kauma¯ tuatanga tae noa atu ki nga¯ tau whakamutunga o te rangatira i roto i nga ringa manaaki, ringa atawhai o te ha¯ pori.

Older people live well, age well and have a respectful end of life in age- friendly communities.

Citation: Associate Minister of Health. 2016. Healthy Ageing Strategy. Wellington: Ministry of Health.

Published in December 2016 by the Ministry of Health PO Box 5013, Wellington 6140, New Zealand

ISBN 978-0-947515-84-3 (print) ISBN 978-0-947515-85-0 (online) HP 6514

This document is available at health.govt.nz

This work is licensed under the Creative Commons Attribution 4.0 International licence. In essence, you are free to: share, ie, copy and redistribute the material in any medium or format; adapt, ie, remix, transform and build upon the material. You must give appropriate credit, provide a link to the licence and indicate if changes were made.

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Foreword Associate Minister of Health

Older New Zealanders are a large and growing proportion of our population – by 2036, one in four of us will be aged 65 years or older. We all deserve our best support to age well, live healthy, independent lives and to have a respectful end of life.

I commissioned this revision of the Government Health of Older People Strategy to help is committed to the goals of positive ensure that the resources of our health ageing, where older people age system remain focused on providing well and are healthy, connected, that support and empowering people. independent and respected. It sets the direction for the health At its heart, the Healthy Ageing sector and outlines the actions needed Strategy is about people. Its priority to improve the health outcomes and is adding life to years not just years independence of older people in a to life. People age in different ways, sustainable way. and our population is diverse. We I have rebranded it the Healthy Ageing must recognise the range of ways Strategy for several reasons. We are older people access and interact with all ageing, in different ways, and don’t services. necessarily become ‘old’ when we We need a multi-faceted and reach the age of 65. Healthy ageing coordinated approach to improve recognises the diversity of older people, the health and wellbeing of our older and ultimately seeks to maximise health people, particularly those living with and wellbeing into and throughout long-term conditions, with high and people’s older years. complex needs or in population groups The Healthy Ageing Strategy is aligned that are experiencing poorer outcomes with the wider New Zealand Health from our health system. Our health Strategy. It also has strong links the system also needs to meet the health Positive Ageing Strategy. Older people and support needs of an increasingly make a significant contribution to and ethnically diverse population. have an integral role in our society. The

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This will require the health and social Many people and organisations have sectors to work collaboratively and for been involved in developing this everyone in New Zealand to recognise Strategy. This reflects the wide variety the important role that family and of those who care about and influence whānau carers play in supporting older people’s health and wellbeing. our older people in their homes and I would like to thank everyone who has communities. contributed.

As well as enabling and supporting I would especially like to acknowledge older people to age well, this Strategy the input of older people and their focuses on ensuring older people have family and whānau carers. Your a respectful end of life. Older people contribution has been particularly need to feel safe and supported to important in helping shape the Strategy openly discuss and plan their end-of- and the services it provides. life care. The health system needs to be Hon Peseta Sam Lotu-Iiga responsive to older people’s wishes. Associate Minister of Health

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Foreword Director-General of Health

With the release of the New Zealand Health Strategy, now is the right time to set out a refreshed strategy for the health of older New Zealanders – the Healthy Ageing Strategy.

Its predecessor, the Health of Older peoples’ health People Strategy, was launched in 2002. and wellbeing in The 2002 strategy delivered many later life. successes, including greater choice in The Healthy Ageing Strategy has been long-term health care services. We can written with this goal in mind. It has a all be proud of that. strong focus on prevention, wellness However, the social and demographic and support for independence. It also picture in our country has changed recognises the importance of family, over the past 14 years. In 2002, whānau and community in older when the current strategy was people’s lives. It gives greater priority published, those aged over 65 made to equity and supporting the most up 11.5 percent of the New Zealand vulnerable, including those with high population. That amount has now and complex needs and in the final climbed to 15 percent and is set to stages of life. In addition, it signals the climb further. This has significant need for government agencies, health implications for policy, planning, service care providers and all who seek to design and delivery. make a positive difference to health and wellbeing to work together. Better We must ensure our health system integrating health and social responses provides the care, support and treatment will help us to be more responsive to that older New Zealanders need and that New Zealanders’ needs and choices. level of care is sustainable. We want a health system that works for every older The five New Zealand Health Strategy New Zealander. themes support the Healthy Ageing Strategy actions. These themes – Achieving this means taking into people powered, closer to home, account all the factors that impact on value and high performance, one

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team and smart system – articulate were involved in creating this strategy: the wider system in which the goals from individuals to families and whānau, of the Healthy Ageing Strategy can be carers, health professionals, service achieved. providers, government and non- governmental organisations. We all have I believe this strategy provides us with an ongoing role to play in helping every a clear focus and vision for where we older New Zealander live well, get well need to head. As with the New Zealand and stay well. Health Strategy, the Ministry of Health will provide the leadership needed I’d like to thank everyone who has to help all the organisations involved contributed to the Healthy Ageing play their part in the required actions, Strategy. I look forward to working with changes and focus. you as we deliver it.

Leadership in this context is not about Chai Chuah being in charge or having all the Director-General of Health answers. Many people and organisations

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Contents

Foreword Associate Minister of Health iii Foreword Director-General of Health v Acknowledgements viii Why a Healthy Ageing Strategy 1 Strategic context 4 Taking a life-course approach 8 Challenges and opportunities 10 Vision and priorities for action 16 Ageing well – Te pai o nga¯ tau o te kauma¯tuatanga 18 Acute and restorative care – Nga¯ tua¯huatanga manaaki, whakaora i te hunga ma¯uiui 25 Living well with long-term conditions – E noho ora ana i roto i ngā mauiuitanga o te tinana 32 Support for people with high and complex needs – He tautoko i te hunga pakeke he uaua, he maha hoki o ra¯ tau taumahatanga 37 Respectful end of life – Te mate rangatira i nga¯ tau whakamutunga o te hunga pakeke 41 Turning the Strategy into action 45 Action plan 48 References 68

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Acknowledgements

The Ministry of Health has received • Dr Michal Boyd, Senior Lecturer, valuable input from over 200 written School of Nursing and Department submissions on the draft Health of of Geriatric Medicine, University of Older People Strategy (now Healthy Auckland Ageing Strategy) by the closing date • Stephanie Clare, Chief Executive, of 7 September 2016. Five regional Age Concern New Zealand workshops also collected input from • John Collyns, Executive Director, hundreds of participants around the Retirement Villages Association country, including researchers, district • Hamish Crooks, Chief Executive, health boards, clinicians, primary Pacific Homecare health and other non-governmental • Dr Ken Greer, Clinical Advisor, organisations, older people, carers, and Primary and Integrated Care, Capital aged-care, Māori and Pacific providers. and Coast District Health Board Earlier rounds of engagement • Vui Mark Goshe, Chief Executive, workshops had provided a high Vaka Tautua degree of confidence around the • Julie Haggie, Chief Executive, Home overall approach and themes of the and Community Health Association draft Strategy. The public consultation • Sir Matiu Rei, Director, Ora Toa process on the draft focussed largely on • Robyn Scott, immediate past Chief identifying whether the right actions had Executive, Age Concern New been developed and given priority. Over Zealand 2000 people were involved in those Strategy development workshops. • Simon Wallace, Chief Executive, New Zealand Aged Care Association The Ministry would like to particularly • Sarah Clark, Director, Office for acknowledge the contribution of the Seniors (ex-officio member) expert advisory group: • Blair McCarthy, Acting Director, • Dr Janice Wilson, Chief Executive, Office for Seniors (ex-officio Health, Quality and Safety member). Commission (Chair)

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Why a Healthy Ageing Strategy

Everyone is ageing, and everyone wants to age well. That New Zealanders are living longer than ever before is a major success story, and many older New Zealanders are healthy, active and resilient.

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Remaining in good health, ageing well ‘old’ at any particular age or in the same and being able and supported to live way. Ageing is only partially associated well with long-term conditions, however with chronological ageing and it does complex, is critical to enable older not ‘start’ at 65. Some older people people to continue participating and remain independent and competent, feeling valued (two important factors for both physically and mentally, health and wellbeing). throughout their older years. Some enter their older years with long-term or We have a good base to build on, with chronic health conditions or disabilities, many significant improvements to the and their needs become more complex health and disability support system for as they age. Others develop disabilities older people since the release of the and become dependent as they age, 2002 Health of Older People Strategy. due to cognitive and physical decline, For example, we are supporting more and conditions such as dementia. people than ever with long-term health conditions and disabilities to remain in We need to ensure our system is truly their homes for longer. We also provide people-centred and appropriate to New more consistent and comprehensive Zealand’s growing ethnic diversity. needs assessments, greater choice and improvements in the quality of home Our system and services must and community services and aged aim to keep people in good residential care. Moreover, access to health for longer, recognising elective surgery has improved, as have that older people have discharge practices. different needs at different We want to maintain the positive times. changes we’ve seen over the last 14 years and improve on them in People with the highest needs may be the current context. Our operating those who have the fewest resources environment and the strategic context and the least capacity to address those in which we work have changed. We needs. need a new strategy that expands on This document sets out a strategy for the strengths of the past and sets the the health and wellbeing of older people direction for improved performance and for the next 10 years. outcomes across the board. It is the result of extensive engagement The Healthy Ageing Strategy (the with older people, their families, whānau Strategy) is for older people, their and carers, aged-care providers, health families and their communities. Older care professionals, professional bodies, people are by no means a homogenous researchers, Māori and Pacific peoples population group. We don’t become and their service providers, government

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agencies, district health boards communication and empathy in (DHBs), primary health organisations health care, and for providers to help (PHOs) and other non-governmental older people articulate and listen to organisations (NGOs) that represent what is important to those people in and support older people. their care • a call for more flexible services that Hearing the voice of older people was respond to people’s individual needs especially important in developing and diversity, but where people this strategy, and many older people can expect to have the same level provided feedback and were involved of access wherever they are in the in forming the Strategy’s actions. country They came from a wide variety of backgrounds and offered many different • a clear appreciation of the quality of perspectives, aspirations and ideas health care about ageing. • an expectation for a highly integrated, well-coordinated, While it is important not to generalise, responsive health system their feedback covered some notable, • acknowledgement of the tangible consistent themes, including: benefits of technology, provided no • the desire to be connected and one is excluded or left behind. respected There are three parts to this document. • a need to reduce barriers to The first part introduces the strategy participation in society, to keep and the context in which it exists. active physically, mentally and The second section presents the socially overarching direction for the health • enthusiasm for age-friendly system for the next ten years with communities respect to the health and wellbeing of • a keenness to be empowered to take older people. The third section is the responsibility for their health, and to action plan: specific actions we intend develop the skills to do so to take to address the health and • the importance of good wellbeing requirements for older people and achieve the desired outcomes.

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Strategic context

The New Zealand Health Strategy provides the overarching framework and directions for our country’s health system.

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The New Zealand Health Strategy The Disability Strategy was informed describes the future we want, identifies by the United Nations Convention on the cultures and values that underpin the Rights of Persons with Disabilities, this future and sets out five strategic ratified in 2008. The Healthy Ageing themes for changes we can make that Strategy is consistent with the articles will take us toward its vision. of the Convention.

All New Zealanders live well, stay Positive Ageing Strategy well, get well, in a system that is Government has a long-standing people-powered, provides services commitment to the vision and principles closer to home, is designed for of the cross-government New Zealand value and high performance, and Positive Ageing Strategy 2001, as works as one team in a smart reiterated in 2013 in Older New system. Zealanders – Healthy, Independent, New Zealand Health Strategy vision Connected and Respected.

The New Zealand Health Strategy Older New Zealanders: healthy, provides the building blocks for this independent, connected and Healthy Ageing Strategy. Together they respected. define how we will maintain and improve Cross-government New Zealand Positive healthy ageing and independence, Ageing Strategy 2001 regardless of people’s health status, and provide better support for older people Government agencies are working with with high and complex needs and at the local government, towards a ‘vision of a end of their lives. society where people can age positively and where older people are highly New Zealand Disability valued and recognised as an integral Strategy part of families and communities’. The New Zealand Disability Strategy also informs the Healthy Ageing Treaty of Waitangi and He Strategy. It presents a long-term plan Korowai Oranga for: The health of older Māori is a priority for A society that highly values the this strategy. We recognise and respect lives of people with disabilities the special relationship between Māori and continually enhances their full and the Crown through the Treaty of participation. Waitangi. In the health and disability

New Zealand Disability Strategy vision

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sector, this involves working to the ‘Ala Mo’ui – Pathways to principles of: Pacific Health and Wellbeing • partnership: working with iwi, hapū, 2014–2018 whānau and Māori communities to ’Ala Mo’ui: Pathways to Pacific develop strategies for Māori health Health and Wellbeing 2014–2018 is gain and appropriate health and the Government’s national plan for disability services improving health outcomes for Pacific • participation: involving Māori at all peoples, families and communities. ‘Ala levels of the health and disability Mo’ui has four priority outcome areas: sector, including in decision-making, • systems and services meet the planning, development and delivery needs of Pacific peoples of health and disability services • more services are delivered locally in • protection: working to ensure Māori the community and in primary care have at least the same level of health as non-Māori, and safeguarding • Pacific peoples are better supported Māori cultural concepts, values and to be healthy practices. • Pacific peoples experience improved broader determinants of health. Pae ora: Healthy Futures for Māori Other national plans and wai ora, whānau ora, initiatives . mauri ora Other specific national strategies, action plans and work programmes Our approach to improving Māori health influence the health of older people is guided by He Korowai Oranga, Māori and guide programmes and services Health Strategy. He Korowai Oranga on ways to meet their needs. These has an overarching goal of pae ora, include: which translates to healthy futures for Māori. Pae ora comprises wai ora • New Zealand Framework for (healthy environments), whānau ora Dementia Care (healthy families) and mauri ora (healthy • Improving the Lives of People with individuals). Pae ora encourages Dementia everyone in the health and disability • Primary Health Care Strategy sector to work collaboratively, and to • Living Well with Diabetes: A plan for work across sectors to achieve a wider people at high risk of or living with vision of good health for everybody. diabetes 2015–2020 Implementation of He Korowai Oranga • The New Zealand Carers’ Strategy across the health system recognises and Action Plan 2014–2018 and respects the principles of the Treaty.

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• Pharmacy Action Plan 2016–2020 Organization (WHO) Global Strategy on • Rising to the Challenge: The Mental Ageing and Health 2016–2020, a Health and Addiction Service five-year strategy for action to maximise Development Plan 2012–2017 functional ability for all, and build the • Review of Adult Palliative Care evidence and partnerships for a Decade Services. of Healthy Ageing from 2020 to 2030. The Global Strategy’s five strategic The Healthy Ageing Strategy objectives are: incorporates several aspects of these • commitment to action on healthy population, service improvement and ageing in every country condition-related strategies and work • developing age-friendly environments programmes. • aligning health systems to the needs of older populations Global Strategy on Ageing • developing sustainable and equitable and Health systems for providing long-term care Internationally, New Zealand is (home, communities, institutions) a signatory to the World Health • improving measurement, monitoring and research on healthy ageing.

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Taking a life-course approach

How well we age is influenced by our genetics, our upbringing, how healthily we live in our younger years and throughout our adult life and our exposure to health risks including poor housing, workplace discrimination and family violence.

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Also highly influential are our physical ageing’ does not refer to the absence of and mental capabilities; our access disease or physical or mental ill health. to resources and opportunities; WHO defines healthy ageing as ‘the our resilience including in the face process of developing and maintaining of adversity; our relationships; our the functional ability that enables personal circumstances, including our wellbeing in older age.’ occupation, level of wealth, educational Initiatives for older people that take attainment and gender; our potential for a life course approach, promoting personal growth; and our cultures and ‘healthy ageing’, focus on building sense of identity, security, value and and maintaining people’s physical wellbeing. and mental function and capacity, This strategy applies a life-course maintaining independence and approach to achieving the aim of preventing and delaying disease and healthy ageing. It recognises that we the onset of disability. Such initiatives age in different ways and have different aim to maintain quality of life for older needs at different times, and that our people who live with some degree of health is affected by our environment. illness or disability requiring short or The approach involves enhancing long-term care. They enable disabled growth and development, preventing people to do the things that are disease and ensuring every person important to them, enhancing their functions to the highest capacity participation, social connection and possible throughout their life. ‘Healthy appropriate care and ensuring their dignity in later years. Figure 1: A life-course framework for healthy ageing

High and stable Declining Significant loss

Functional ability

Intrinsic Capacity

Prevent chronic conditions Manage Health services or ensure early detection Reverse or slow advanced and control declines in capacity chronic conditions

Support capacity- enhancing Long-term care behaviours Ensure a dignified late life

Promote capacity-enhancing behaviours Environments Remove barriers to participation, compensate for loss of capacity

Source: WHO 2015

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Challenges and opportunities

New Zealand’s population is ageing. There will be a substantial increase in the number of older people over the next decade.

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This older population, and our Currently, over one in six older people communities, will also become more are living with three or more long-term ethnically diverse. The Māori population conditions. Based on existing trends, of people aged 65 and older is projected an increasingly older population will to increase by 79 percent in the 10 years mean steadily increasing health care to 2026. The older Pacific population is needs. As a population group, older expected to increase by 63 percent, and people have much higher rates of long- older Asian population by 125 percent in term chronic health conditions, and this same period. disabilities that require support on a daily or regular basis. The changing population has major policy, funding and planning We are living longer, but the age to implications. We need to plan well which we are likely to live in good health to make sure we are well equipped and without disability is not increasing nationally, regionally, economically at the same rate as life expectancy. At and socially. We need to have the right the age of 65, people can expect to infrastructure in place to keep people in live half of their remaining lives either good health and provide for those who free of disability or with functional are not. limitations that can be managed without assistance. Figure 2: Population projections by age group with 10 year percent change This is not the same for Population (million) Age all population groups. In 5.5 90+ a comparison of Māori 45% 85–90 5 40% 75–84 and non-Māori males and 57% females, Māori males aged 4.5 65–74 31% 65 can expect the shortest 4 remaining time of living 13% 55–64 without disability or long- 3.5 8% 45–54 term illness (5.5 years on 3 average) and the highest

2.5 proportion of remaining time 14% 25–44 lived with disability requiring 2 support (64 percent). 1.5 People with intellectual 1 1% disabilities have some of the 0–24 .5 poorest health outcomes and can develop dementia 0 2015/16 2025/26 2035/36 at a younger age. Year

Source: Statistics New Zealand, 2016 Healthy Ageing Strategy 11

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Figure 3: Māori and non-Māori life expectancy for a whole-of-system approach at age 65 to achieving, balancing and 85 measuring improved health and equity for all populations, best value for public health system 80 resources and improved quality,

80.4 82.5 84.1 86.6 safety and experience of care.

To achieve equity, we need to 75 understand and remove the barriers that prevent groups from experiencing equitable health 70 outcomes, and build on the 70.5 74.4 75.6 75.7 factors that enable equity. We need to work together with other 65 sectors to address a range of Ma¯ori Ma¯ori non-Ma¯ori non-Ma¯ori males females males females barriers. The existing barriers we know about are infrastructural, Years with disability Years without disability financial and physical. Others can Source: Ministry of Health, 2013 be difficult to articulate or identify.

Figure 4: New Zealand Triple Aim Health inequities Framework Improved health and equity for all populations We need to continue our efforts to reduce inequities in health, so that all population groups can enjoy good health and participate fully in family Population and community life. In this respect, the Ministry of Health (the Ministry) focuses specifically on the health of Māori, Individual Quality Improvement Pacific peoples, migrant and refugee communities, people with disabilities, System people with long-term mental health Improved quality, safety and experience of care conditions or addictions and people with Best value for public health system resources low incomes, who experience persistent We need to better understand how well inequities. our services are working for different Achieving equity is a core component population groups, and why problems of the ‘value and high performance’ arise. This has implications for the theme of the New Zealand Health way that the health sector conducts Strategy. This is underpinned by the research, collects data and evaluates New Zealand Triple Aim Framework the effectiveness of services.

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Staying healthy and services. These approaches provide independent in older age significant opportunities for improving the health of New Zealanders in general We have an opportunity to reinforce and older New Zealanders in particular. and accelerate the positive trends we One example of a social investment have seen in recent years. By focusing approach might be a concerted effort on preventing illness and by making it across government to reduce social easier to choose healthy options (like isolation and loneliness, which we eating healthy food, not drinking alcohol know have a strong relationship or only drinking at low-risk levels, and with poor mental and physical undertaking regular physical activity), health outcomes and with increased we can help people to avoid developing problematic alcohol use. long-term health conditions or slow the development of those conditions. Most importantly, we can do this by Workforce development providing universal health services The health system faces some and public health initiatives that cover significant workforce challenges. The the whole population and by having health of older people workforce is services in place to intervene early and itself ageing and some key workforce help people to return to good health groups have experienced recruitment and remain independent. As part of this, difficulties. For example, forecasts show we need tailored approaches for some that we will have trouble maintaining the individuals and population groups, to necessary number of geriatricians and help them access the same level of some other medical specialties, as well service and enjoy the same outcomes as registered and enrolled nurses, in as others. aged care.

New investment approaches As people live longer with long-term conditions and complex needs, either If we continue to fund health services in at home or in aged residential care, the way we currently do, care of older we will increasingly need to support people will account for 50 percent of and develop the skills of our nursing, DHB expenditure by 2025/26, up from allied and kaiāwhina (unregulated care 42 percent in 2015/16. It is vital that we and support workforce) workforces. ensure we are getting the best value Some initiatives to sustain and grow from the investments and resources the workforce are under way, including across the health and social sectors. incentives to encourage graduate nurses to the sector and programmes The Ministry and other government to support teams working together departments are taking new ‘social across all settings. However, these are investment’ approaches to funding

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not yet achieving significant gains. We Many are led by older people, together need to be smarter in the way we make with local councils and a variety of use of different parts of the workforce, organisations, who work towards local such as the well-qualified pharmacist solutions to optimise older people’s and allied health workforces. opportunities for healthy ageing, participation, security and quality of We need to make a priority of attracting, life. Age-friendly communities provide retaining and making the best use of new opportunities for developing the skills in the health workforce to knowledge and skills for healthy ageing, meet the needs of an older population. and for the health sector to partner with We need to ensure workforce training older people in developing health and keeps pace with technological change, resilience. and retraining is easily accessible for staff, and is efficient and effective. Integration across the We also need to ensure that our health health and social sectors workforce appropriately reflects our growing ethnic diversity and ensure that Our approaches to the health and it appropriately reflects and caters to a care of older people need to change diverse older population. at multiple levels. We need better communication between health service users and providers, to ensure that Families and communities services are as effective and efficient We also need to ensure that family and as they can be. We need to improve whānau carers receive support and the abilities of families, whānau, information to be able to appropriately carers and communities to support and safely care for older people. These and help care for older people. The carers should also be supported health system needs to work with to maintain their own health, and other sectors to take joint action on the undertaking a caring role should social, environmental and economic not exacerbate any existing health determinants of people’s health. Good conditions or disabilities. housing and transport, for example, are critical to keeping people well in their We are starting to see the development own communities. of age-friendly communities in New Zealand. This term refers to More collaborative approaches will communities that commit to physically enable us to be efficient and innovative accessible and inclusive social living in the way we utilise specialist environments that promote healthy and roles, such as nurse practitioners, active ageing and a good quality of life, clinical nurse specialists and all particularly for those in their later years. health professionals including allied

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health professionals, such as dental view of performance. Three of the hygienists, dieticians, occupational measures in particular (acute hospital therapists and radiographers; bed days per capita, patient experience pharmacists and paramedics, to of care and amenable mortality rates) improve outcomes and enable highlight significant opportunities to innovative models to develop in home improve the health outcomes of older care, primary health care and residential people. care. We’re also able to make use of new technologies and information Smart system improvements. These technologies Today’s health system is data-rich, with and improvements include initiatives a tremendous volume of information that enable information to flow quickly that can be harvested to create a much and freely to older people and to health smarter system. workers, providers and families and whānau; apps that provide immediate The value and high performance theme information on an older person’s of the New Zealand Health Strategy health status; and social media, which emphasises the performance of the improves health professionals’ options whole system and recommends for connecting with older people, the development of an outcomes- families, whānau and carers in diverse based approach to performance or isolated communities and helping measurement. The Ministry has them to connect more easily with the worked closely with the health sector services and information they need. to develop a suite of system-level Improved information flows will also measures that provide a system-wide help agencies to collaborate more widely.

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Vision and priorities for action The vision for this Strategy is that: Older people live well, age well and have a respectful end of life in age-friendly communities.

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To achieve this vision, we need to • better support older people with ensure our policies, funding, planning high and complex needs and service delivery: • provide respectful end-of-life care • prioritise healthy ageing and that caters to personal, cultural and resilience throughout people’s older spiritual needs. years These five outcome areas form the • enable high-quality acute and framework for this Strategy. We will restorative care, for effective set out to achieve our vision in these rehabilitation, recovery and five areas within a system that, as the restoration after acute events New Zealand Health Strategy requires, • ensure older people can live well is people powered, delivers services with long-term conditions closer to home, is designed for value and high performance and works as one team in a smart system. Figure 5: Strategic framework for healthy ageing

People- powered

Ageing well Smart Closer to system home Support for people Living well with with high Respectful health and end of life complex conditions needs Acute and restorative care

Value and One team high performance

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Ageing well Te pai o nga¯ tau o te kauma¯tuatanga This outcome area is about: • maximising people’s physical and mental health and wellbeing throughout their lives • developing health-smart and resilient older people, families and communities to help older people age positively • achieving equity for Māori and other population groups with poorer health outcomes • taking actions to improve the physical, social and environmental factors of healthy ageing • supporting the development and sustainability of age-friendly communities that enable older people to age positively.

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Why this is important Investing in healthy ageing has the potential to increase the proportion of Health is fundamental to being able healthy, active and independent older to live well, age well and continue to people, prevent long-term conditions participate in family and community and their impacts on people’s lives and life. Older people make a significant result in long-term savings to the heath contribution to our society, economically, system. socially and intellectually as mentors, leaders and skilled workers and A healthily ageing and robust volunteers. A healthy ageing approach population would help enable seeks to enable older people to continue individuals to continue participating to be active, engaged and enjoying life. in their communities and contributing economically, socially and intellectually While people may experience some to a greater extent. Fewer people would loss of strength and mobility over time, require acute health interventions many of the conditions associated and would be able to stably maintain with ageing (such as frailty) are not themselves if they developed chronic inevitable. The WHO estimates that health conditions. more than half of the health conditions older people experience are potentially To ensure people age well, we need to avoidable through lifestyle changes. focus on: There is increasingly clear evidence • building physical and mental that healthy lifestyles and physical and resilience mental resilience are determinants of • achieving equity in health across all health in older age. There are also many population groups opportunities to benefit longer term from • developing a health smart population investing in social and environmental through health literacy and helping factors that influence health. people to plan for their future health Ageing well is not just about preventing and health-related needs ill health and disability. It is also about • a health system that supports healthy maximising physical and mental health ageing closer to home and wellbeing, independence and • supporting people to plan for future social connectedness as people age. health and health-related needs Healthy ageing relates to all older • improving social, physical and people, including people with life-long environmental determinants of health disabilities or long-term conditions, • promoting and supporting the those recovering from injuries or poor development of age-friendly health, those with high and complex communities. needs and those in their final stages of life. Subsequent chapters build on this chapter.

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Resilience that promotes older people’s sense of self-worth and value to others. Resilient people are more likely to age We need to continue to reduce the well and avoid cognitive decline or stigma of depression and anxiety loss of function until very late in life. among older populations, and promote Resilient people can overcome stressful the factors and supports for greater obstacles and recover from events that mental wellbeing. We need to foster might tip a less resilient person into a approaches that build people’s state of poor health. strengths and capabilities, increase Resilience develops through physical optimism and hope and reduce the activity, healthy behaviours, mental potential and impact of depression, wellbeing and social connectedness. anxiety and cognitive decline. Our focus is therefore on increasing physical activity and other healthy Equity behaviours among older people – for Reducing health inequities is a core example, encourage good nutrition, not component of a healthy ageing drinking alcohol or only drinking at low- approach and a priority for government. risk levels, not smoking tobacco, taking Equity is defined by the WHO as ‘the part in mentally stimulating activities absence of avoidable or remediable and relationships that build people’s differences among groups of people, strengths and resilience. whether those groups are defined People staying active and connected socially, economically, demographically as they grow older is critical. There is or geographically.’ Health equity strong evidence that social isolation or approaches aim to improve fairness loneliness is linked to poor mental and and reduce the incidence of avoidable, physical health outcomes. We need to undesirable differences in health status. increase awareness of this fact across People differ in their ability to attain the health system, and join with social or maintain good health, for many sector agencies, as well as community reasons. Some population groups and voluntary organisations to reduce have markedly poorer health outcomes: this risk factor and increase social Māori, Pacific peoples, people with interaction and connectedness. intellectual disabilities, and people We must also improve mental in socioeconomically deprived wellbeing among older people. Social areas. Other groups, such as ethnic connectedness, nutrition, physical communities and rural communities, health and activity all contribute to are also vulnerable to poorer health mental health, as does an environment outcomes.

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Our focus on health equity aims to Empowering and supporting older increase the age which these groups people to be ‘health smart’ in their later can expect to remain in good health years requires the health system to and independence and includes: have a strong understanding of what • ensuring equity of access to health it takes to age well and takes part services, including through innovative in achieving healthy ageing. We will and effective services provided support older people in a way that is closer to home, and catering to meaningful for them, and that is fully people’s cultural preferences inclusive, where people are at the • enabling equal opportunities to raise centre of the process. We will make the capacity, functional ability and health information available and shared wellbeing, by directing resources at in a way that overcomes cultural and those with greatest need communication barriers. • removing physical, financial, Planning for the future institutional and other barriers to high-quality health services and People’s needs change as they age, equitable health outcomes and there may become a time when a person is no longer able to make • working across government and decisions or advocate for themselves. in communities on the social Advance care plans and enduring determinants of health, including powers of attorney allow an individual housing, elder abuse and neglect, to retain a degree of autonomy in negative attitudes and discrimination, relation to their health care and social isolation and inclusive, age- treatment, minimise the potential for friendly communities conflict or harm, and reduce stress on • minimising the impact of disability family members and others. There is and illness on people’s lives. some evidence that advance care plans can improve the experience of end-of- Being health smart life care and their use across clinical Health literacy disciplines is an integral part of a dying People are empowered in their person’s coordination of care. everyday lives when they can make Advance care plans and the decisions that positively affect their discussions around them create an health and care. Health literacy is the opportunity for people to think and capacity to make good decisions, act talk about their values, preferences on health information and navigate and beliefs. These conversations are the health system. It is an essential easier when they begin well before component of resilience and a priority the end of life. However, as people’s of this Strategy. preferences often change over time, it

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is also important that they be reviewed A strong, well organised primary health and updated at key points and when care system that is provided close circumstances change. to where people live and work will empower individuals, enabling them to The New Zealand Health Strategy make informed choices and supporting commits to supporting people and them as they navigate their way their clinicians to develop advance through the health system. They also care plans by building on existing reduce health inequities and improve national and international resources population resilience. and networks. We can also promote advance care planning through, for example, community organisations, Improving the social and to help reduce stigma around talking environmental factors about death and dying, and to increase influencing health the likelihood that people receive quality Together with other government sectors health care according to their wishes. and communities, the health system will The quality of care is further discussed work to improve the social, economic in the ‘Respectful end of life’ section. and physical factors for healthy ageing We know that financial security is also and achieve equity, removing barriers to important for mental wellbeing and participation. healthy ageing. The Commission for Financial Capability is carrying out a We need a coordinated, system-wide national strategy and leading work approach to preventing, identifying and across government and together with reducing elder abuse and neglect that communities to grow New Zealanders’ includes providing accessible, well- financial capability. Better financial tailored, effective services. As part of capability will improve family and the Ministerial Group on Family Violence community wellbeing, reduce hardship, and Sexual Violence work programme, increase investment and grow the the health, social and justice sectors economy, contributing to everyone’s are working together to develop an resilience. integrated system for preventing and responding to family violence and sexual violence, including elder abuse High-quality care closer to and neglect, and reducing the impacts home of such violence on wellbeing. The work Primary health care services are is built around people-centred service generally people’s first interaction with design and delivery, in the four areas the health system when they are unwell. of primary prevention, identification, They are where people receive most of incident response and follow-up their professional medical advice. responses.

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We will work with housing providers Age-friendly communities to improve the quality and range of and workforce age-friendly housing for older people. Age-friendly communities are This will include a focus on rental accessible and inclusive. They value housing stock, which older people people of all ages, and optimise are increasingly likely to live in, and opportunities for healthy ageing, supported living housing options. We including in the areas of participation, will work with social housing providers dignity, security, and quality of life. to ensure that social housing is warm, Age-friendly communities ensure safe and dry, and with others to older people have a voice, including promote options for housing that meet those with disabilities and dementia, the needs of an ageing population. and marginalised older people. They We will also look for opportunities with recognise older people’s wide range the housing development sectors to of skills and resources, and ensure understand the future housing needs of that communities protect those who an ageing population. are most vulnerable. They anticipate Transport solutions are needed to and respond flexibly to the changing reduce social isolation and improve physical, mental and social needs and older people’s ability to participate in preferences of older people and ageing their communities and access health populations. and other social services. Government The ‘age-friendly’ concept and its agencies will work with transport implementation have significant providers to increase access to momentum internationally and is alternative means of transport for older starting to gain pace in New Zealand. people, to help prevent isolation. They The Office for Seniors will lead the will work to increase the flexibility of development, through a co-design social services in areas where transport process, of a New Zealand-centric options are most limited. approach, and further develop the Whānau ora service approaches are resources and networks to guide examples of how agencies can work communities through the process of well together to reduce the social, becoming age-friendly. physical and environmental barriers Across central and local government some people face to achieving good agencies, and in partnership with health and wellbeing. communities, we will support older people and promote age-friendly communities throughout New Zealand. We will support older people and others leading age-friendly communities

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locally. Together we will work to Goals for healthy ageing improve policies, services, structures • Older people are physically, mentally and environments, particularly outdoor and socially active, have healthy spaces and buildings, transport, lifestyles and greater resilience housing, social participation, respect throughout their lives, meaning that and social inclusion, civic participation they spend more of their lives in and employment, communication, good health and living independently. and health and social services. Our collaboration will enable collective • Older people are health smart, able impact at the national, regional and to make informed decisions about local levels. their health and know when and how to get help early. An integrated health workforce with • Everyone in the health system and in knowledge of social determinants of the wider social sector understands health, culturally competent and with what contributes to healthy ageing, a focus on wellness and upstream and takes part in achieving it. early intervention in supporting healthy • All older populations in New Zealand lifestyles is an important contributor to are supported to age well in ways age-friendly communities. appropriate to their needs and cultures. • Communities are age-friendly with initiatives to keep people healthy, well-connected, independent, respected and able to participate fully in their communities and with family and whānau.

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Acute and restorative care Nga¯ tua¯huatanga manaaki, whakaora i te hunga ma¯uiui This outcome area is about: • ensuring appropriate admissions to hospital for older people with acute or urgent clinical/care needs • coordinating care across specialities and between ACC and the health sector • ensuring hospital stays are safe for older people who are frail, vulnerable or have dementia • helping older people to regain, maintain or adapt to changed levels of function after an acute event • looking for ways to weave family or whānau and wider community support into an older person’s recovery and ongoing functioning.

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Why this is important However, at the other end, premature discharge may result in loss of Older people benefit from access to functioning or condition in the older a wide range of hospital services, person or even readmission. Premature including emergency or acute services. discharge can also cause significant But unnecessary emergency visits, and stress for family, whānau and carers inappropriate admissions are stressful who feel unprepared and unsupported. for the individuals and use valuable resources. When an older person returns home after a stay in hospital, they may need to Ambulance services and emergency make adjustments to their daily routines, departments are generally the first and they may require temporary or services to deal with acute and ongoing support. Re-integration to potentially life-threatening situations. family, whānau and community life is a But they may not be the best places for key goal at this stage. older people whose conditions could be managed at home or by their local Successful treatment of an acute event primary health care clinics or aged and effective follow-up care are reliant residential care homes. on proactive and integrated planning, timely treatment and a team approach. Once in hospital, older people can Planning needs to involve the individual be especially vulnerable to rapid and their family and whānau and should deterioration putting them at risk of address physical, mental and spiritual further harm, (eg, by acquiring an aspects. infection). Service providers and staff need When older people stay in hospital to understand cultural and other too long, they face the risk of further preferences, and be committed to decline in their health associated with working with Māori, Pacific and other reduced physical activity (leading to organisations, families, whānau and loss of muscle tone and the chance of community leaders to get the best bed injuries), stress leading to increased outcomes possible for individuals. confusion, and inappropriate medication. Older people told us that they want their: These factors can lead to loss of • urgent care needs managed at the confidence and social contact and right level (that is, don’t take them are strong predictors of increased to hospital if they don’t need to go length of stay, long-term cognitive there) impairment, complications or death, as well as higher costs for care. They can • assessment and other important also mean a slower recovery for the information to be available to all who individual and increased distress for need it (that is, not to have to repeat family, whānau and carers. their information several times over)

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• families, whānau and carers involved Family and carers could be the ‘eyes in their rehabilitation and planning for and ears’ of an older person’s care their return home team and initiate timely interventions.

• discharge, ongoing rehabilitation, Some DHBs have developed ‘pathways home support and equipment of care’, that is, guidelines for assessing organised in a timely way. and managing particular conditions (eg, Therefore we will focus on improving strokes or heart disease) to improve the three main parts of the journey the coordination and documentation for older people – managing acute of care. Such pathways can reduce presentations, providing safe, quality unplanned referrals to hospital. treatments in hospital stay, and We need to spread innovations that ensuring supported discharges and reduce the need for unnecessary rehabilitation into the community. intensive services.

Managing acute Ambulance services in the Kāpiti Coast region, out of Wellington, are using an presentations ‘urgent community care model’ and To reduce unnecessary admissions, Healthline, as well as frontline triaging in we need a system-wide response, emergency departments. Gerontology including prevention, timely primary nurse specialists in the Waitemata health care responses for older DHB provide assessments and care people with acute needs, better coordination across primary health communication between providers and care and hospital services for complex systems, coordinated clinical and social wound care to be managed in the home care, links between regular hours and or aged residential care setting, thus after-hours services, and engagement reducing the risk of an older person’s with community providers. health deteriorating and the need for acute care. The first stage of the journey is prevention. A range of people can We will encourage and support such have a role in this stage, including innovations, evaluate their outcomes general practitioners, pharmacists, and spread good practice. physiotherapists and home support workers. All these primary care Safe, quality treatment in givers should be able to recognise a hospital deteriorating or acute situation and know where to go for further advice before Hospitals can be frightening and calling on emergency care services. bewildering places. Hospital staff need to be acutely aware of the vulnerability of older people, especially those who

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are frail, experience dementia, have cultural preferences and practices, for complex conditions or disabilities or example, by creating enough space could become delirious. to accommodate extended family and whānau, can help improve the patient Many older people have multiple and family experience of care. conditions, which can lead to transfers between specialists or hospital Around one-third of deaths among older departments and lack of overall people occur in hospital, including in coordination. We need geriatric acute settings. Links with palliative care specialists to assist with assessments services are therefore critical. Advance and care planning. Equally important, care plans (ie, documentation around a range of health professionals the goals and limits or ‘ceilings of care’) need to be trained to deal with the and enduring powers of attorney need common conditions and complications to be readily accessible. associated with caring for older people.

A comprehensive collection of clinical Supported discharges, and personal information will already rehabilitation and exist for some older people, for example restorative care through an interRAI assessment or ‘Rehabilitation’ refers to the process gathered by their primary or community by which health providers assist a health care team. There is scope for person to recover from a procedure these providers to share information or event and regain, maintain or attain to improve care planning and reduce as much functioning as possible. The duplication. Such information needs term ‘restorative care’ is also commonly to be accurate, accessible, easy to used to refer to the building up of a interpret and up to date. person’s capacity and resilience to Joint initiatives between ACC, the maximise their autonomy. Ministry and the Health Quality and Preparation for being discharged home Safety Commission New Zealand are needs to begin as early as possible, underway to reduce patient harm and and it is critical to engage the family or improve analysis and data sharing on whānau and carers who will be involved patient safety and treatment injury. in providing on-going support in the This work aims to enable continuous home and community as well as the quality improvements and help reduce various members of the clinical care disparities in care between injury and team. This is commonly referred to as non-injury patients. ‘early supported discharge’.

Space and time are often short in Internationally, there is not a large body hospital, especially in emergency of consistent evidence on the best way settings. Nevertheless, respecting to transition people from hospital to

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home. But there are promising models working with people to help them regain already in use and plenty of scope for or maintain their ability to manage their further trials and evaluation. We need day-to-day needs. to support innovation, collect data For some people, this will mean finding and share results to build the body of a new balance – adapting to changed evidence and develop best-practice or reduced levels of functioning, approaches. including addressing the psychological Some DHBs have dedicated teams and social effects of this change, for to plan and manage ‘early supported example after a stroke. discharge’, for example START Clarifying an individual’s goals and and CREST Team in Waikato and motivations is a key part of developing Canterbury DHBs respectively.1 Such a personalised care plan, and provides teams have been shown to be effective a way to recognise and respect cultural in reducing a person’s time in hospital, preferences. preventing readmissions and lower costs overall. Family and whānau involvement is critical to supporting the older person In other areas, district nursing services through their rehabilitation, and it is provide clinical care and oversight of important to identify any help the carer rehabilitation – sometimes home based, needs to be able to provide that care in sometimes in a community clinic. a safe and sustainable way. Some people need longer periods of Volunteer groups can also play a time to recover and a different setting valuable role, (eg, stroke support or and benefit from a ‘step-down’ or cardiac companion groups). ‘intermediate care’ provided after discharge from hospital, but before it is possible for them to return home. Integration in the health sector and across agencies For example, in some parts of the country, aged-residential care facilities Funding for rehabilitation and recovery provide a safe place for ongoing services is currently spread across rehabilitation, which also includes different parts of the health system, training for family, whānau and carers. including health, disability and ACC (and occasionally New Zealand Wherever rehabilitation occurs we are Veterans’ Affairs). This can lead to looking for a shift in philosophy from duplication of services, or gaps and simply doing things for people, to delays in coordinating care (eg, a person needing home care, district nursing, nutrition advice and equipment 1 Supported Transfer and Accelerated Rehabilitation Team and the Community may face four different assessments). Rehabilitation Enablement and Support.

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Streamlining assessments, Kaiāwhina and family or whānau standardising the use of shared need to be involved in rehabilitation. care plans and routinely using multi- Information sharing, training and other disciplinary teams might make any means of support could enhance funding differences invisible to the the range of support activities person needing services. they undertake, and improve their confidence and ability to provide Workforce ongoing care throughout the rehabilitation period. A variety of different workforces with complementary skills support the health The health and disability workforce and wellbeing of older people. In all needs to be able to respond to our settings, staff need an understanding ethnically diverse population and of common conditions for older people to deliver services and supports in such as frailty, confusion, falls, or risk culturally competent ways. factors such as incontinence pressure injuries or polypharmacy. Quality Ideally, there should be multi- Quality measures in this area need to disciplinary teams involved in care include individual experiences and planning and delivery. This ensures outcomes; for example, can the person comprehensive coverage, and now dress themselves? Was the person coordinated care. Integrated technology satisfied with their recovery? Did their and tools (such as shared electronic family or whānau feel supported to help records) can provide greater flexibility with their rehabilitation? by supporting ‘virtual’ teams’ Quality measures can also include We need a skilled generalist workforce ‘system’ measures, such as the number and a specialist workforce that provides of acute bed-days, and contributory both clinical services to individuals, and measures, such as whether discharge training and support to allow other staff was timely and support services were to work to the top of their scope. in place, and whether the person was readmitted to hospital within a short Allied health staff (such as occupational time. and speech language therapists, dieticians and physiotherapists) have Quality is an ongoing process that key skills for rehabilitation, recovery and needs to be supported by the provision restoration, but access to them can be of up-to-date evidence to inform and limited. Greater integration will rely on spread best practice. more flexible access to such staff.

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Technology Goals for acute and Arrangements are in place in most restorative care areas of the country to ensure that • Innovations and research support primary health care practices are best practice triage, assessment, advised whenever a person uses an integrated care, discharge planning, ambulance or emergency department rehabilitation strategies, and follow- service. This needs to be available up support. across the country, and potentially • Older people are supported through extended to other areas such as aged recovery by specialists and general residential care. staff who are competent to deal An increasing array of electronic with common conditions, including reminders and measurement and frailty, delirium or dementia. Hospital monitoring tools are available to assist staff and processes respect cultural rehabilitation. We want to see both preferences and differences. health professionals and older people • Family, whānau and carers are supported to use such tools effectively. included in discharge planning and receive training and support Shared patient records that include to provide ongoing rehabilitation in assessment information and care plans home and community settings. and that indicate how people want to • Quality measures include patient be treated at their end of life, are critical experiences as well as clinical to support care coordination. outcomes.

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Living well with long-term conditions E noho ora ana i roto i ngā mauiuitanga o te tinana

This outcome area is about: • giving individuals the tools and support they need, including guidance, information and access to technology, to manage their long-term conditions to a comfortable level and reduce the impact of those conditions on their lives • ensuring all health professionals and social services have the tools and support they need, including information and resources, training, models of care and access to technology, to detect long-term conditions at the early stages and treat, rehabilitate and manage them well • improving social assistance, primary health care and home and community services and supporting family and whānau carers to help older people with long-term conditions live well • improving our ability to slow or stop the progress of long-term conditions towards frailty.

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Why this is important dependence on long-term support services or family and whānau. The WHO has referred to long-term health conditions as ‘the health care Higher rates and greater complexity challenge of this century’. Long- of long-term conditions will increase term conditions include diabetes, demand for health services in general, obesity, cardiovascular and chronic and home and community support obstructive pulmonary disease services in particular. This will also (COPD), cancer, asthma and other mean that increasing numbers of respiratory conditions, arthritis and people will be caring for and supporting musculoskeletal diseases, stroke, family and whānau members. chronic pain, dementia, mental illness The New Zealand Health Strategy’s and addiction. Long-term conditions overarching goal is to see all New also include physical, sensory and Zealanders live well, stay well and intellectual disabilities. get well, and therefore spend more of With an ageing population, the their lives in good health. As part of numbers of people living with long-term a healthy ageing approach, for those conditions are expected to increase. with long-term conditions, our focus Long-term conditions can occur at is on reversing or slowing declines in any age, but become more prevalent health and function, and promoting and and are more common among older supporting the behaviours and other people. Currently one in six older New factors that enhance people’s capacity. Zealanders are living with three or more We want to ensure that older people long-term conditions. For example, with long-term conditions retain the the numbers of New Zealanders with highest level of mental and physical dementia is expected to rise to 78,000 function possible; they enjoy life, and by 2026, from an estimated 50,000 their communities respect them. currently. Some population groups, To achieve these goals, we will take such as people with intellectual steps to improve the detection of disabilities, and Māori and Pacific long-term conditions, including where peoples tend to have higher rates of mental health and addiction issues long-term and age-related conditions at are involved, which may mask as well earlier ages. as contribute to symptoms of other Long-term conditions are often long-term conditions. We will help New complex, with multiple causes. They Zealanders become more health smart, can lead to a gradual deterioration so that they are better able to manage of health and mobility but can also their conditions and get the help they become acute suddenly, resulting need to stay well. We will improve in hospitalisation and sometimes the health workforce’s ability to work

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with older people who have long-term functional impact, and improving our conditions so that those people are able approaches to enablement can make to live well with their condition, and we a signficiant difference to how well will strengthen home and community people are able to live and participate in support services so that they are better everyday life and remain independent. equipped to support people with long- term conditions and their family and Priority populations whānau. Long-term conditions contribute to the higher rates of illness, disability and Prevention and detection death experienced by Māori, Pacific A major theme of the New Zealand peoples, people on low incomes and Health Strategy is to have New people with disabilities. We will prioritise Zealanders become more health smart. reducing health inequalities and other To create a health smart population, adverse outcomes for people with long- we need to provide individuals, as well term term conditions. as family and whānau and carers, with We need to ensure that older people information about preventing long-term of all ethnicities are health literate conditions. and can access culturally appropriate For those living with long-term services including home and respite conditions, we need to provide care, long term residential care, mental information about specific conditions, health and dementia services. The symptoms, medication and health workforce should also reflect our management, as well as the importance growing ethnic diversity. We will do this of healthy lifestyles. We also need to in partnership with these population enable people to connect with groups groups and their families and whānau, and organisations that can help them to and the providers and NGOs that manage their conditions. represent these population groups.

We need to improve our ability to Dementia is particularly prevalent prevent and manage long-term long-term condition in older ages, conditions that lead to the development and an important priority. We will of frailty. implement the New Zealand Framework for Dementia Care (see Ministry of There are a number of ways in which we Health 2013) to give people who are can minimise the harm of sensory loss living with dementia the best possible and the loss of functional ability in older independence and wellbeing. people. Timely recognition of emerging sight and hearing issues, for example, Living well with long-term conditions using appropriate assessments for requires identification, interventions,

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information and advice relevant to need assistance to remain living at specific conditions. We will investigate home for example through medicine and, where appropriate, deliver relevant optimisation services. approaches for people living with stroke, We need to accelerate improvements musculoskeletal conditions, dental in the models of primary health care to conditions, low vision and diabetes. ensure that it is able to respond to the challenges of a diverse older populations Enabling technology with higher rates of co-morbidities. Technological tools such as In the case of home care, we could smartphones, apps and wearable better align service models, funding devices have many valuable methods and levels of training, to allow applications in the area of health. They a greater level of involvement with other will become increasingly important parts of the health system. At present, as a way of allowing older people the home and community workforce is to maintain autonomy, dignity and a fragile. Jobs in this sector are generally better quality of life, including through characterised by low pay, irregular the ability to remain living in their own working hours and variable access to homes for as long as they wish. The training, which contributes to high staff pace at which older people adopt such turnover. tools will vary. We need to ensure that late adopters continue to have equal We will invest in the home and access to the services they require. community support workforce and develop service and funding models. Health workforce and Models will take a sustainable, culturally service delivery appropriate, equitable and person- centred approach to supporting older As the proportion of older people in our people with long-term conditions. This society grows, the health workforce will will include consideration of the role of need to become more adept at caring individualised funding and retirement for them, and more knowledgeable villages. about what keeps older people healthy and resilient. We will expand the Family and whānau capability of the workforce through professional development and smarter Family and whānau carers play a vital models of working. role in providing support for older people with long-term conditions. We Primary health care, pharmacists and will ensure that such carers receive the home and community support services support they need. This will include are well placed to take a greater role training and information, as well as in the care and support of people who

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different, flexible forms of respite care are actively self-managing their so that they can look after their own conditions to a practical and wellbeing, in particular their mental comfortable level and are supported health. Family and whānau carers should to do so closer to home. not be in a position where they become • The workforces that support older isolated because of their caring role. people with long-term conditions, including the health workforce, home Goals for living well with and community support services long-term conditions and family and whānau carers, collaborate and have appropriate • Improved methods of early detection resources, structures and training and prevention result in fewer older and work in an integrated manner. people being affected by long-term • Home and community support conditions or frailty. services are equitable and • Older people with long-term appropriate to older people’s needs conditions retain the highest level and preferences and maximise their of mental and physical function wellbeing. possible; they enjoy life and their • Health outcomes for vulnerable older communities respect them. populations with long-term conditions • Older people with long-term are equitable, with good outcomes for conditions are ‘health smart’, the population as a whole.

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Support for people with high and complex needs He tautoko i te hunga pakeke he uaua, he maha hoki o ra¯ tau taumahatanga

This outcome area is about: • building on the vision and actions of previous outcome areas to consider issues particularly relevant for older people with high and complex needs • ensuring people are in the right place to receive the care and support that most appropriately meets their needs • individuals maintaining choice and control when they need significant support • helping families and whānau to provide the best support they can while maintaining their own wellbeing • coordinating, integrating and simplifying health and social services for older people with high and complex needs • providing flexible home and aged residential care services that suit the needs of the increasingly diverse older population • reducing avoidable visits to emergency departments and acute care among a group of potentially high users • enabling all older people with high and complex needs to easily access care and support, irrespective of their financial position • promoting innovative models of complex care that better support older people, their family and whānau and carers • ensuring value and high performance for services that use a large proportion of the health budget.

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Why this is important usual to make choices about the care or support they want to receive; clarity Older people with high and complex of communication is vital. needs are one of the most vulnerable groups in society. They are more likely Some older people with high and to become ‘frail’; that is, to deteriorate complex needs have lost or are losing markedly after an event that would their mental capacity to make full commonly have a minor effect on other and rational choices, so health care older people’s health. The number and providers need to communicate their complexity of conditions in older people care options with a wider group, with high and complex needs makes including family and whānau and carers. treatment and care more difficult, as Older people with high and complex conditions and treatments affect each conditions have to navigate their way other. through more parts of the health and For some people with high and complex support system than other older people. needs, moving into aged residential These services need to communicate care improves the quality of their lives in and work well together to ensure such their remaining years. people are well supported with their health care. This part of the Strategy expands on the goals and actions relating to long-term conditions. Doing more to support older Technology people with high and complex needs is Technological tools such as particularly relevant for the population of smartphones, apps and wearable Māori and Pacific older people with high devices are making it increasingly and complex needs, given the higher easier to monitor a person’s health and rates of Māori and Pacific people in this communicate health information. Health category. There are good examples of service providers will pay particular health practitioners, purchasers and attention to each individual’s ability to providers partnering with Māori and use such devices and accommodate a Pacific providers to develop services range of technical literacy levels. that meet the needs and aspirations of Māori and Pacific people in culturally Services closer to home appropriate ways for individuals and their families and whānau. Older people value their independence highly. They do not want to be seen as Knowledge and a burden on spouses, family or social communication services. They want to stay in their communities, and access services Older people with high and complex closer to home. High performing needs require more information than primary care and home care service

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models referred to in the long-term systems, people’s experience, service conditions chapter are particularly quality and the impact of services on important for people with high and whānau. complex needs. We will also strengthen To achieve best value and high health and social sector coordination, performance, DHBs will commission workforce and support family and services that provide older people community in their roles are carers. with quality care in the right setting at a sustainable cost. This can involve Health and social sector identifying potential health issues and coordination instituting preventive care plans in Older people who are developing response. higher and more complex needs New Zealand’s health system needs generally receive better care when their to better support the older population primary health care service is close to groups that do not enjoy the same their home. It is easier for the health health as New Zealanders as a whole. professional caring for them to have These groups include Māori and Pacific more regular contact with them and peoples, disabled people and those know more about their situation and with long-term mental health issues and their lives. alcohol and other drug addictions.

Older people who need to see a Our focus will be on removing barriers variety of health professionals want to delivering high-quality health their individual health information to services, within the health sector and be available to all the clinicians they between it and other sectors. Improving see so they don’t have to retell their the health of vulnerable groups may story repeatedly. We will develop involve better tailoring services for systems so that clinicians are informed accessibility, available at more suitable about patients’ other conditions and times, or delivered in more culturally treatments. appropriate ways. Health services for older people with high and complex needs can be very Workforce expensive. We will therefore be careful People working in teams that contain with our use of resources so we can a range of health specialties need to help more people. We will design care see themselves as part of one team for older people with high and complex supporting integrated care that is needs with value and high performance provided closer to home. We will reduce in mind. Our approach will take into the barriers that currently prevent account the full range of influences on people from using their skills flexibly older people’s outcomes, including the and fully. resources across the health and social

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The workforce needs to ensure that Goals for supporting people the services are culturally appropriate with high and complex needs to meet the needs of a wide range of ethnic communities. Older people with high and complex needs: Support workers make up a large part • are able to live as independently and of the workforce for people with high actively as possible and complex needs. We will pay, train • have the information and freedom to and value these workers as part of the make good choices about the care integrated ‘one team’. and support they receive Family and community • know that health care workers understand their wishes and support Beyond the formal workforce, we will their needs support families and whānau and others • are assured that information about in their roles as carers of older people their circumstances and needs flows with high and complex needs. This easily between health care workers support could involve health literacy who work in an integrated manner education, and training specific to the • have care plans that reduce the carer role, and having regard for the likelihood they will deteriorate carers’ own health needs, particularly in markedly after a health event relation to mental health. • are able to access care and support Older people with high and complex irrespective of their financial position needs often have comprehensive • experience equitable access to clinical assessments of their needs services and equitable outcomes electronically recorded in the interRAI regardless of ethnicity or rural database. Care providers use this location information to develop care plans. The • move easily to and through care information will be a rich resource for settings that best meet their needs the range of health professionals dealing • have reduced need for acute care. with each person and for PHOs and DHBs learning about the outcomes of Families and whānau and carers have older people receiving support services the support, information and training in a location or population group. they need to assist older family members, and the stress of caring does not affect their own health.

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Respectful end of life Te mate rangatira i nga¯ tau whakamutunga o te hunga pakeke

This outcome area is about: • respecting the goals and preferences of people in their last stages of life • tailoring care to the physical, emotional, social and spiritual needs of the individual and their family and whānau • continuing to provide high-quality palliative care and preparing the health system for future palliative care needs • providing coordinated care that meets all individuals’ needs, wherever they are • supporting family and whānau and friends to support dying older people.

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Why this is important their family and whānau and friends helps them all come to terms with the Death is a universal experience, dying process. It aims to be a positive and also a deeply personal one; our influence on the course of illness, and experience in the last stages of life can to enable the person to live their regular be profoundly important for us and day-to-day life as much as possible those close to us. until their death. It seeks to give the This outcome area builds on the person space to be themselves, four others. At the end of life we achieve their goals and to interact with continue to manage conditions, often their family and whānau and friends as in complex combinations requiring much or as little as they need. good coordination. A person in the We need to ensure that people at the last stages of their life can still be last stages of their life are in control of subject to episodes of acute illness and their care as much as they are able, recovery, just as those in acute care and that their preferences are well can unexpectedly take a turn for the understood and adhered to as much as worse and require end of life care. The practical by those involved in their care. ultimate goal for the end of life is to achieve optimal wellbeing, physically, New Zealanders hold many different socially, emotionally and spiritually. world views; they have different cultural and spiritual needs and different In the last stages of life, what expectations about the end of life as commonly matters to people are: to well as ideas about family, community feel accompanied by their family and and life in general. As a health system whānau and friends, to be confident we should acknowledge and respect that their symptoms and pain are the diversity of our older population, controlled well, attention to spiritual and the profound emotional and and cultural needs, and to receive good spiritual significance of the end of life information, communication and well- process. coordinated care. We should expect, and take steps to ensure a person at Achieving a respectful end of life the end of their life will receive high- for Māori, Pacific and other ethnic quality palliative care that respects their communities requires all health wishes. practitioners and services and personnel to be particularly aware of High-quality palliative care involves the physical, mental, social and spiritual relieving the distressing symptoms needs of individuals, their families and and physical pain of a person with a whānau. A good understanding of life-threatening or terminal condition. It tikanga is also essential. regards dying as a normal part of life, provides support for the person and

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Increasing the emphasis on as support, advice and education. primary palliative care Shared clinical records, patient portals and other technologies will support this As our population ages, more people integrated service delivery. will die each year. Many will have uncomplicated deaths, but as we live longer, we can expect increasing Improving quality in all numbers of people with more complex settings conditions and comorbidities, including Palliative care takes place in a variety dementia, requiring more specialised of settings, including in hospitals, care. As a health system, we will need to aged residential care, hospices and make sure we can consistently provide individuals’ homes. Ideally, it takes end of life care to a high standard and place where a person wants to be that we have the capacity to meet future and where they feel safe, comfortable demand. We need to embed palliative and supported. It is coordinated care as a core element of practice by a qualified individual or a multi- across the broader health workforce disciplinary of the person’s choosing. and ensure this workforce is adequately supported by a highly trained specialist Sometimes the onset of the last stages workforce. of life is quicker than expected, and a person can spend their last hours There are opportunities to use a dying somewhere unanticipated. To range of professions better, including ensure seamless care, we need to in pharmacy and allied health, to support, up-skill and use the existing improve the quality of palliative care, for skills and experience of staff across example, through medicine optimisation all health care settings to ensure they services. Pharmacists, physiotherapists, are adequately prepared to provide occupational therapists, speech and palliative care as needed. language therapists, dieticians, social workers and psychologists, practice As part of the work towards improving nurses and others can be involved in the quality of end-of-life care in all ensuring wellbeing in the last stages settings, we need to understand and of life. measure the key indicators of good palliative care, including from an If our primary health care workforce is individual and whānau perspective. trained in core palliative care practices, There needs to be national agreement we should be able to continue to on what constitutes quality end-of-life meet people’s palliative care needs. care, and we need to enforce quality However, it will require an adequate standards that apply to all areas of the specialist palliative care workforce to health system to ensure we provide provide specialist clinical care as well consistently good palliative care.

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Growing the capability of care is person-centred, and identifying carers and communities areas for improvement. Families and whānau and carers can We will take steps to accommodate be intimately involved in the dying people’s wishes the best we can, and process and can make an invaluable respond to what people, and their contribution to the experience of the friends and family have told us in order dying person. We need to support to continually improve palliative care. these carers well and recognise the importance of their role and the impact Goals for enabling a of caring for a dying person. respectful end of life We can improve the support we provide • The health system responds to older informal carers, by providing respite, people’s goals and care needs at the information, guidance, and training end stages of life, and the experience to lift their skills and confidence. We of their family, whānau, caregivers need to work with employers to ensure and friends involved in their end-of- informal carers are respected in the life care. workplace and to reduce any work- • All health care teams are responsive related barriers to their caregiving. to the cultural needs of different groups. Responding to the voices of • Health service providers coordinate people with palliative care palliative care to ensure all providers needs and their families and in the health system are used to whānau their fullest. All of those who support people dying in old age are aware of Clear communication is an essential the dying person’s plans and know factor to good quality end-of-life care. their own role in achieving those The health system must strive to ensure plans. that a dying person’s goals and wishes • People die feeling as comfortable have been well articulated, understood and safe as possible. and respected by all involved in their care at every levels. • Expert advice and support is available to families and whānau, Information on people’s experiences, other carers and the health workforce including bereaved people, is an involved in end-of-life care. invaluable tool for ensuring palliative

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Turning the Strategy into action

Achieving the vision and goals set out in this strategy requires the commitment of many people across and throughout the health and social system, working in partnership with NGOs, communities, older people and their families and whānau.

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It also requires us to have the right set listed alongside each action. However, of actions, and the right leadership and each action is given a specific lead who systems in place to implement those takes on accountability for achieving actions and keep us on course. that action.

A package of actions is set out over the following pages to implement Implementing the action this strategy over a 10-year period. plan The actions were developed in The action plan will be implemented discussion with older people and in several phases. Actions that will be their representatives as well as other implemented over the first two years stakeholders from the health and social are shown with an asterisk (*). However, system across New Zealand. it is recognised that some of these The actions are organised under the actions will require longer than two strategy’s goals, so that they are years to fully implement. appropriately outcome-oriented in The Ministry will develop an accordance with a life-course approach. implementation plan with major There are links and inter-dependencies partners, setting out the finer details of across the actions and common themes the actions, including the mechanism, that will mean that some of them will be timing, sequencing, responsibilities and developed and implemented together resourcing required for each one. through cross- and intra-sectoral teams. These include: Implementing these actions will rely on skilled leadership, solid partnerships • actions focused on vulnerable and and participation across the health and high-needs older population groups social systems. We need this strategy • actions focused on information, tools to represent a shared vision for the and resources and other enablers future, and we need to work together to • actions including referral pathways achieve our aims. and other aspects of systems for integration, which would be linked A system of continuous for a system-wide approach to integration. improvement The health system is, and operates in, Equity and workforce are considered a complex and dynamic environment across all the actions. within a highly networked system Implementing the actions will involve with multiple inter-dependencies. We a variety of stakeholders from across are limited in our ability to predict the the health and social sectors, as well future, so we need to be mindful and as older people and their families and flexible and ready to adapt in order to whānau. Many of these partners are stay on track.

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We recognise this Strategy is a living communities in which older people live document. The Ministry will review and older people themselves. the action plan after two years. The We have a wealth of data and review will look at how well the actions knowledge to inform our next steps, are being delivered and how effective including through our investment they are. We may need to adjust some in interRAI and research initiatives, actions, replace them or combine them such as the Ageing Well National with other initiatives to strengthen their Science Challenge (see: www. chance of success. Implementation ageingwellchallenge.co.nz). In addition, will always need to fit to the available the development of New Zealand’s resources, and we will need to prioritise first health research strategy will help the initiatives. us build a more cohesive and effective While the Ministry is responsible for health research and innovation system. putting together the Strategy and We will harness these opportunities to reporting on its progress, continuous ensure that we make the best use of improvements to health services and current information and improve our health outcomes for older people will understanding of healthy ageing. require all relevant parties to remain Ultimately, we will ensure that involved and committed. This includes information and our investment in, and a wide variety of service providers, the the outcomes of, research inform policy development and service improvement.

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Action plan

Ageing well goals

• Older people are physically, mentally and socially active; have healthy lifestyles and display greater resilience throughout their lives, meaning that they spend more of their lives in good health and living independently. • Older people are health smart, able to make informed decisions about their health and know when and how to get help early. • Everyone in the health system and in the wider social sector understands what contributes to healthy ageing and actively works to achieve it. • All older populations in New Zealand are supported to age well in ways appropriate to their needs and cultures. • Communities are age-friendly, with initiatives to keep people healthy, well-connected, independent, respected and able to participate fully in their communities and with family and whānau.

Lead Actions Partners

1. Develop and support the growth of age-friendly communities. a. Promote­ the concept of age-friendly communities • • • Office for nationally and in communities and workforces.k Seniors b. Provide advice and tools to support older people, local National, government and others leading the establishment and regional development of age-friendly communities and builds the and local knowledge base for an age-friendly New Zealand.k government agencies and c. Build strong partnerships between DHBs, Healthy NGOs, older Families New Zealand, public health units, PHOs and people other age-friendly communities for effective healthy ageing community initiatives in communities.k members

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Lead Actions Partners

d. Develop, through a co-design process, a New Zealand- centric approach to age-friendly communities that:k – draws from the WHO framework for age-friendly cities – builds on local experience – includes a networked infrastructure at national, regional and local levels.

2. Increase physical and mental resilience. a. Increase­ the availability of strength and balance • • ACC programmes in people’s homes and community Health Quality settings.k & Safety Commission New Zealand, Ministry of Health, DHBs b. Expand the provision of targeted health literacy • DHBs initiatives, and services to increase resilience among Government Māori, Pacific and other priority older populations who agencies have poorer health status. c. Review the Green Prescription programme, including the • Ministry of potential for other health professionals to prescribe and Health improve its utilisation by older people. DHBs, primary health care d. Increase understanding and explore partnerships in • Ministry of promoting mental health for older people at an individual, Health organisational and community level.

e. Encourage services and providers to promote healthy • • DHBs eating, physical activity and healthy lifestyles.k health organisations, NGOs, New Zealand Nutritional Foundation

f. Encourage­ services and providers to promote the Health reduction of alcohol-related harm.k Promotion Agency k Implemented in the first two years • People powered • Closer to home • Value and high performance • One team • Smart system

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Lead Actions Partners

3. Work across government on the socioeconomic determinants of health to prevent harm, illness and disability and improve people’s safety and independence. a. Work across government and social sector agencies to • • Ministry improve access, and coordinate assistance to socially of Social isolated and other vulnerable older people and develop Development, initiatives that better address the physical and social DHBs, other determinants of health. government agencies, PHOs, other NGOs b. Participate in the cross-government Ministerial Group on • • • Ministry Family Violence and Sexual Violence Work Programme.k of Social Development, Ministry of Justice c. Update the 2007 Family Violence Intervention Guidelines: • Ministry of Elder Abuse and Neglect, and promote their uptake by a Health wider range of health professionals. d. Establish a cross-government working group to identify • Ministry and progress opportunities to improve housing options of Social for older people and better enable older people to live in Development age- and disability-friendly homes. Ministry of Business, Innovation & Employment Ministry of Health, Local Government New Zealand, Housing New Zealand e. Support initiatives that maximise healthy ageing through • Ministry of supported housing and age-friendly communities where Business, this will also contribute to regional economic and social Innovation & development.k Employment Te Puni Kōkiri, Ministry of Health

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Lead Actions Partners f. Promote volunteering, networking and paid work among • Ministry older people, as a means to support their sense of of Social wellbeing and social connection. Development NGOs, health providers g. Increase the accessibility for older people of the • Ministry of built environment and transport services through the Transport implementation of Priority 10(a) of the Disability Action New Zealand Plan. Transport Agency

4. Improve health literacy. a. Strengthen the capability of the workforce in provider • • DHBs organisations to understand the range of health literacy needs of older people, and improve the accessibility and responsiveness of services. b. Enhance health promotion and service information to • DHBs Māori, Pacific peoples and other ethnic communities Primary health and priority groups to enable greater accessibility and care engagement. c. Improve the effectiveness of health literacy information • Ministry of distributed by health and social sector agencies. Health Health Promotion Agency d. Support­ older people’s uptake of technologies for • DHBs communication with health providers and their family and Primary health whānau.k care e. Increase­ the accessibility of information on healthy • Ministry ageing and health and social services through govt.nz, of Health Your Health, SuperSeniors and links to other websites, Government so that people can be more ‘health smart’.k agencies f. Increase­ public and workforce awareness about and • Ministry of use of advance care planning and enduring powers Health Office for of attorney across the health sector, government and Seniors, Ministry community agencies and amongst older people and their of Social carers.k Development, community organisations k Implemented in the first two years • People powered • Closer to home • Value and high performance • One team • Smart system

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Acute and restorative care goals

• Innovations and research support best practice triage, assessment, integrated care, discharge planning, rehabilitation strategies, and follow-up support • Older people are supported through recovery by specialists and general staff who are competent to deal with common conditions, including frailty, delirium or dementia. Hospital staff and processes respect cultural preferences and differences • Family, whānau and carers are included in discharge planning and receive training and support to provide ongoing rehabilitation in home and community settings • Quality measures include patient experiences as well as clinical outcomes.

Lead Actions Key partners

5. Reduce inappropriate acute admissions and improve DHBs assessment processes. Primary health a.­ Support initiatives to reduce unnecessary acute • • care providers, admissions, for example by extending paramedic emergency roles, improving after-hours clinical support for aged response services, residential care facilities, using intensive home-based aged residential support, developing acute geriatric care pathways and care providers, applying proven technological solutions.k needs assessment b.­ Work with the health sector to streamline acute service providers, assessment tools and processes and spread best home and practice options.k community support providers

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Lead Actions Key partners

6. Improve treatment and outcomes for older people in hospital due to acute ill-health or injuries. a. Promote­ and implement evidence-based models of • ACC care to:k Ministry of – improve the patient journey and experience, Health, Health including for those with delirium, dementia, and Quality & Safety common frailty symptoms Commission New – improve the quality of care for those admitted for Zealand, DHBs falls and fractures, including hip fractures – enhance early supported discharge planning – ensure patient experience and cultural responsiveness are reflected in quality measures.

b. Make­ use of data to identify older people at risk of falls • ACC and fractures, to target and coordinate investments Ministry of and interventions.k Health, Health Quality & Safety Commission New Zealand, DHBs 7. Support effective rehabilitation closer to home by • Ministry of working across the whole system. Health a. Work with the sector (including service users) to DHBs, primary identify and promote best practice in:k care providers, aged-residential – rehabilitation partnerships with primary health care, care, home allied health, community nurses, pharmacists, aged support providers, care providers, home support providers, family and older people, and whānau carers – home-based and community-based models that support ongoing rehabilitation and restoration of older people – facilitating staff working in rehabilitation to collaborate across workforce groups and work to the top of their scope. k Implemented in the first two years • People powered • Closer to home • Value and high performance • One team • Smart system

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Living well with long-term conditions goals

• Improved methods of early detection and prevention result in fewer older people being affected by long-term conditions or frailty. • Older people with long-term conditions retain the highest level of mental and physical function possible; they enjoy life, and their communities respect them. • Older people with long-term conditions are ‘health smart’, are actively self-managing their conditions to a practical and comfortable level and are supported to do so closer to home. • The workforces that support older people with long-term conditions, including the health workforce, home and community support services and family and whānau carers, have appropriate resources, structures and training. • Home and community support services are equitable and appropriate to older people’s needs and preferences and maximise their wellbeing. • Health outcomes for vulnerable older populations with long-term conditions are equitable, with good outcomes for the population as a whole.

Lead Actions Key partners

8. Improve models of care for home and community Ministry of support services. Health DHBs, aged- a. ­Identify and implement models of care that are person- • • centred, needs-based and equitable, and deliver high- care providers value, high-quality and better outcomes through home and community support services across New Zealand. As part of this work:k – involve service users and their family and whānau – review the role of needs assessment and service coordination – ensure needs assessment and care planning are culturally appropriate and meet the needs of Māori and other priority population groups. b. ­Use interRAI assessment data to identify quality • Ministry of indicators and service development opportunities Health including with health providers.k DHBs, aged care providers

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Lead Actions Key partners

9. Ensure that those working with older people with long- term conditions have the training and support they require to deliver high-quality, person-centred care in line with a healthy ageing approach. a. ­Regularise and improve training of the kaiāwhina • Ministry of workforce in home and community support services.k Health DHBs, aged care providers b. Ensure undergraduate and graduate curricula support • • • Health an integrated model of care that: Workforce – enables all health professionals to work as one team New Zealand – works in partnership with older people and their Tertiary training family (including cultural understanding of older providers Māori) – promotes healthy ageing and restoration – addresses risk factors for social isolation and mental health and problematic alcohol use. c. ­Progress training packages to enhance the capacity and • • Careerforce capability of kaiāwhina to support people with long-term conditions and their families and whānau, as part of the Kaiāwahina Action Plan.k d. ­Develop a range of strategies to improve recruitment and • Ministry of retention of those working in aged care, beginning with Health an update of the 2011 report Workforce for the care of DHBs, aged older people and development of a whole of workforce care providers action plan.k e. Better utilise the allied health workforce to enhance care • DHBs for older people in primary health care, home care and Primary health aged residential care. care, aged care providers f. ­Enhance workforce capability and training pathways to •• Ministry of encourage more entry and retention of the workforce Health among Māori and Pacific peoples and other ethnic groups.k g. Improve training and information for family carers that • Ministry of helps them to safely and competently carry out their Health caring role and keep well themselves. k Implemented in the first two years • People powered • Closer to home • Value and high performance • One team • Smart system

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Lead Actions Key partners

10. Enhance cross-sector, whole-of-system ways of working. a. Make better use of common points of contact across • • Ministry of the health and social sectors to identify and support Health older people with mental health and alcohol and other Ministry drug problems earlier. of Social Development, DHBs, housing agencies b. Share educational resources and good practice on • • Providers effective ways to increase physical activity levels among older people with debilitating health conditions to support service improvement.

c. As part of implementing the Pharmacy Action Plan 2016 DHBs to 2020 (Ministry of Health 2016), improve medicines management and encourage better liaison between pharmacists and other health professionals including through: – increasing use of brief interventions, screening, • assessment and referral in primary health care, including by pharmacists – sharing examples of innovative models of care • that can be adopted to support pharmacist and pharmacist prescribers’ delivery of medicines management.

11. Expand and strengthen the delivery of services to tackle long-term conditions. a. ­Strengthen the implementation of the New Zealand • DHBs Dementia Framework, and the actions specified in Improving the Lives of People with Dementia (Ministry of Health 2014).k b. ­Work with health and social services and communities • Ministry of to become more dementia-friendly.k Health Office for Seniors, DHBs, Alzheimers New Zealand, Dementia Cooperative and other dementia organisations

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Lead Actions Key partners c. ­Reduce the instances of complications from diabetes, • DHBs particularly for people in aged residential care in line Primary health with Living Well with Diabetes: A plan for people at high care, aged care (Ministry of risk of or living with diabetes 2015–2020 providers Health 2015a), by providing tools, resources and quality standards.k d. ­ Better coordinate and integrate rehabilitation for people • DHBs recovering from a stroke by identifying improvements to Ministry of business models, the workforce and models of care.k Health, aged care providers e. ­ Provide community-based, early intervention • • DHBs programmes for people with musculoskeletal health Ministry of conditions, including through the Mobility Action Health, primary Programme.k health care f. Improve the early identification of mental illness and • Primary health other conditions and addictions, such as problematic care alcohol use, that can mask or contribute to other long- DHBs term conditions.

g Ensure that older people with mild to moderate mental Primary health health conditions are able to access mental health care services in their communities. DHBs

12. Better enable individuals and communities to understand and live well with long-term conditions and get the help they need to stay well. a. ­Promote community support for older people with • • Primary health mental illness and substance misuse issues, to both care reduce the stigma among older people and help them DHBs seek treatment.k b. Ensure home and community support models of care • • DHBs cover advice to and support for older people to remain physically and mentally active, and strengthen skills they may have lost. ­c. Investigate options for rehabilitation services to support • • Ministry of older people with low vision.k Health k Implemented in the first two years • People powered • Closer to home • Value and high performance • One team • Smart system

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Lead Actions Key partners

13. Use new technologies to assist older people to live well with long-term conditions. a. ­ Include health apps targeting older people with long- • • • Ministry of term conditions in the health app library that is currently Health being developed.k b. ­ Promote use of technology options to monitor • • • DHBs conditions and alleviate social isolation, especially Primary health among rural and remote locations.k care c. Promote the use of assistive technologies to support • • DHBs home-care workers to achieve good outcomes.

14. Improve oral health in all community and service settings. a. Develop clinical pathways for optimal dental care • Ministry of throughout ageing and into the end of life, to maintain Health independence and minimise pain. DHBs, PHOs, oral health service providers b. Identify and promote innovative care arrangements • • Ministry of for the oral health care of older people receiving home Health and community support services and living in aged DHBs, PHOs, residential care. oral health service providers, aged care providers c. ­Disseminate updated information and advice on dental • • Ministry of care to older people’s families and carers, and aged- Health care providers.k DHBs, PHOs, oral health service providers, aged care providers

k Implemented in the first two years • People powered • Closer to home • Value and high performance • One team • Smart system

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Support for people with high and complex needs goals

• Older people with high and complex needs: –– are able to live as independently and actively as possible –– have the information and freedom to make good choices about the care and support they receive –– know that health care workers understand their wishes and support their needs –– are assured that information about their circumstances and needs flows easily between health care workers, in an integrated manner –– have care plans that reduce the likelihood they will deteriorate markedly after a health event –– are able to access care and support irrespective of their financial position –– experience equitable access to services and equitable outcomes regardless of ethnicity or location –– move easily to and through care settings that best meet their needs –– have reduced need for acute care. • Families, and whānau and carers have the support, information and training they need to help the older people they care for, and the stress of caring does not affect their own health. • District health boards bring together data from various sources, know the value and quality of the care they provide for older people in their district and can easily learn from other DHBs.

Lead Actions Key partners

15. Focused care of frailty in the community.

a. Explore­ the possibilities for a frailty identification tool to • • Primary health enable primary and other health professionals to identify care frail older people earlier.k DHBs b. Build responsiveness to frailty in primary health care • Primary health settings and improve links to all necessary supports, care treatment and rehabilitation services. DHBs k Implemented in the first two years • People powered • Closer to home • Value and high performance • One team • Smart system

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Lead Actions Key partners

16. With service users, their families and whānau, review the quality of home and community support services and aged residential care in supporting people with high and complex needs and involving family and other caregivers. a. Review the quality of home and community support and • • DHBs aged residential care in supporting older people with Ministry of high and complex needs with service users and promote Health, ACC, service commissioning models that enable such people NZ Aged Care to receive the care most suited to their needs, without Association, unnecessary barriers to moving between care settings aged care or deciding funding sources. providers

17. Integrate funding and service delivery around the needs and aspirations of older people to improve the health outcomes for priority population groups. a. In specific locations, trial commissioning one • DHBs organisation to coordinate the health and support Ministry of services for frail elderly people that: Health, – are strongly person centred and take account of service family and whānau carer needs providers – assist older people to meet their individual objectives – minimise the need for the most expensive health and support services – could include primary health care, pharmacy, ambulance, home and community support, aged residential care and acute care services. b. Ensure that some trials focus on population groups that • DHBs currently have poorer health and social outcomes or are Ministry of not well catered for in current approaches. Health, service providers c. Develop referral systems for older people at risk of or • • DHBs experiencing social and economic isolation through their Government contact with primary care, aged-care needs assessors, agencies, social housing, the ACC and other government NGOs agencies. d. Improve the coordination of health and social services • DHBs to vulnerable older people within health and across the Government social sector. agencies

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Lead Actions Key partners

18. Improve the physical and mental health outcomes of older people with long-term mental illness and addiction. a. Improve access to physical health services among • • DHBs people with high mental health and addiction needs, and Specialist improve integration of these services with residential AOD and care or home care services. Mental Health Services, primary health care, Ministry of Health, NZ Aged Care Association, aged care providers

19. Better integrate services for people living in aged residential care.

a. Develop­ standard referral and discharge protocols • DHBs between aged residential care facilities, pharmacists, NZ Aged Care primary care (including providers of after-hours services Association and and medicines advice), ambulance and hospital aged residential services.k care providers, pharmacists, primary care, ambulance

b. Explore technology options for providing advice and • Ministry of triage for aged residential care facilities, especially after Health hours. c. Ensure systems, resources and training are in place that • Aged allow aged residential care facilities to communicate residential with and involve family and whānau at the point of care providers discharge from hospital or where urgent care is needed. DHBs, Ministry of Health

d. Explore options for aged residential care facilities to • • DHBs become providers of a wider range of services for older NZ Aged Care people such as post-acute restorative care, including Association, non-residents. Ministry of Health k Implemented in the first two years • People powered • Closer to home • Value and high performance • One team • Smart system

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Lead Actions Key partners

20. Improve integration of information from assessment and care planning with acute care services, and with those responsible for advance care planning.

a. Develop systems that collate relevant information and • Ministry of make it readily available at the point of care, as well as Health for planning at all levels. DHBs, primary health care, pharmacists, aged residential care providers, home and community support providers

b. Develop tools and resources for health professionals • • DHBs and providers to support the integration of long-term Service care management, acute care services and advance providers care planning. c. Ensure home and community support staff and, where • Primary health appropriate, social workers and a range of health care professionals, are able to contribute to shared care DHBs, Ministry plans and interdisciplinary teams. of Health, home and community support providers

21. Improve medicines management.

a. Develop education partnerships between pharmacists • DHBs and other health professionals to increase medication Pharmacists, adherence and make better use of pharmacists’ primary health expertise. care, home and community support providers, aged residential care providers b. Implement pharmacist-led medicines reviews for older • • • Primary health people with high needs receiving home and community care support services and those in aged residential care. Pharmacists, Home Support providers, aged residential care providers, DHBs

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Lead Actions Key partners c. Ensure­ models of care and contractual arrangements • DHBs provide equitable access to medicines management Pharmacists, services targeting people receiving high-risk medicines primary health and/or polypharmacy, people in aged residential care and care, home older people with complex health needs living in their own and community homes.k support providers, aged residential care providers

22. Build the resilience and capability of family and whānau, volunteer groups and other community groups that support older people with high and complex needs and those with end-of-life care needs. a. Improve the support for informal carers in alignment with • Ministry the Caring for Carers: New Zealand Carers’ Strategy of Social Action Plan for 2014–2018, including for various types of Development respite care, guidance and information, and training. Ministry of Health, Ministry of Business, Innovation & Employment, ACC k Implemented in the first two years • People powered • Closer to home • Value and high performance • One team • Smart system

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Respectful end of life goals

• The health system responds to older people’s goals and care needs at the end stages of life and to the needs of their families, whānau, caregivers and friends involved in their end-of-life care. • All health care teams are responsive to the cultural needs of different groups. • Health service providers coordinate palliative care to ensure all providers in the health system are used to their fullest. All of those who support people dying in old age are aware of the dying person’s plans and know their own role in achieving those plans. • People die feeling as comfortable and safe as possible. • Expert advice and support is available to families and whānau, other carers and the health workforce involved in end-of-life care.

Lead Actions Key partners

23. Build a greater palliative care workforce closer to home. a. Ensure that core elements of end-of-life care (such as • Ministry of aligning treatment with a patient’s goals, basic symptom Health management and psychosocial support) are an Tertiary integral part of standard practice for all relevant health education professionals and health care workers. providers, aged care providers, other health providers b. Revise national referral guidance for specialist palliative • Ministry of care to better support sector understanding of the Health interface between specialist and primary palliative care. DHBs

c. Better utilise pharmacists, allied health and advanced • Ministry of nursing roles, and specialist palliative care nurses as Health, members of integrated palliative care teams. DHBs, PHOs d. Encourage the use of new technologies to both support • Ministry of people at the ends of their lives to remain in their homes Health, and enable easy access to shared clinical records DHBs and specialised support and advice, such as telecare, e-monitoring and assistance technologies in the home.

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Lead Actions Key partners

24. Improve the quality and effectiveness of palliative care. a. Work with the Palliative Care Advisory Panel to • Ministry of implement the actions from the 2016 Review of Adult Health Palliative Care Services.k b. Develop and agree national service expectations and an • Ministry of outcomes framework for palliative care. Health DHBs c. Support the implementation of Te Ara Whakapiri: • Ministry of Principles and guidance for the last days of life (Ministry Health of Health 2015b).k DHBs d. Progress options for a national survey of patient and • • Ministry of family and whānau carers’ experiences of the care Health provided at the end of life to ensure person centred Health, Quality care.k & Safety Commission New Zealand k Implemented in the first two years • People powered • Closer to home • Value and high performance • One team • Smart system

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Implementation, measurement and review

Lead Actions Key partners

25. Implement the Healthy Ageing Strategy. Ministry of a. With­ health and social sector partners, complete a • • • Health Healthy Ageing Strategy Implementation Plan within the Wide range of first four months of the Strategy’s release.k partners

26. Include older people in service design, development and review and other decision-making processes. a. Work with older people to identify outcomes they wish • • DHBs to achieve from the services they receive and indicators of these desired outcomes when services are being designed or reviewed. b. Ensure there are feedback loops through which PHOs, • DHBs DHBs and the wider health system can learn from Primary health outcomes, including patient experience, and plan for care, ACC service and workforce improvement. c. Improve­ the knowledge of user’s experience in home • Health Quality and community support and in aged residential care for & Safety service commissioning and monitoring outcomes.k Commission New Zealand Ministry of Health DHBs d. Include­ representatives of older people in DHB • DHBs forums.k e. As­ part of implementing the Pharmacy Action Plan 2016 • Ministry of to 2020 (Ministry of Health 2016), co-design a service Health model with consumers to support the development Pharmacists and implementation of a minor ailments and referral DHBs service.k

27. Establish an outcomes and measurement framework, commissioning and review processes. a. Develop a system to evaluate progress against the • Ministry of goals of the Healthy Ageing Strategy and support the Health health system to be person centred and focused on maximising healthy ageing and independence.

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Lead Actions Key partners b. As part of the measurement and evaluation system, • Ministry of include an outcomes framework and indicators to Health assess, support and improve the health outcomes DHBs, health for older people (including where possible relevant providers, measures that are already being produced for other organisations purposes, such as for the Whānau Ora Outcomes representing Framework). These indicators will form contributory older people measures that district alliances can monitor to help them improve on the overall health system level measures. c. Regularly­ review the Healthy Ageing Strategy • Ministry of implementation progress and the prioritisation of Health actions.k DHBs d. Publish­ indicators for each DHB on a regular basis.k • Ministry of Health DHBs e. Develop strategies for lifting performance on indicators • DHBs including researching the reasons for trends and the researchers, reasons for differences from better performing DHBs. Ministry of Health

f. As part of implementing Health Strategy 2016 action • Ministry of 17(c)(iii), improve commissioning models for older Health people’s services to enable streamlined and flexible NGOs contracting that supports providers to be sustainable.

28. Improve the knowledge base. a. Implement a system to collect a minimum dataset on • Health kaiāwhina workforce. Workforce New Zealand b. ­Encourage National Science Challenges to • Ministry of appropriately communicate research relating to Business, older people to a broad audience and encourage Innovation & stakeholders to use the research to inform policy Employment development and service design.k c. ­Ensure alignment between the New Zealand Health • Ministry of Research Strategy, key research initiatives and centres Health with the identified needs of the ageing population, and that the research informs policy and service and workforce development.k k Implemented in the first two years • People powered • Closer to home • Value and high performance • One team • Smart system

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References

Ministry of Health. 2013. New Zealand Framework for Dementia Care. Wellington: Ministry of Health.

Ministry of Health. 2014. Improving the Lives of People with Dementia. Wellington: Ministry of Health.

Ministry of Health.2015a. Living Well with Diabetes: A plan for people at high risk of or living with diabetes 2015–2020. Wellington: Ministry of Health.

Ministry of Health. 2015b. Te Ara Whakapiri: Principles and guidance for the last days of life. Wellington: Ministry of Health.

Ministry of Health. 2016. Pharmacy Action Plan 2016 to 2020. Wellington: Ministry of Health.

Ministry of Social Development. 2014. Caring for the Carers: New Zealand Carers’ Strategy Action Plan for 2014 to 2018. Wellington: Ministry of Social Development.

WHO. 2015. World Report on Ageing and Health. Geneva: World Health Organization. URL: http://apps.who.int/iris/bitstream/10665/186463/1/9789240694811_eng.pdf (accessed 26 October 2016).

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quarterly Project Reporting Status Measures Measures 2017 - 2018 Recent Work Completed Current Activity Major activities planned next Target date and expected quarter outcome/any risks or issues Leadership CCDHB HVDHB WDHB 3 DHB 2017 - 2018 Encourage intersectoral leadership on disability On track Intersectoral leadership In 2017/18, active Partnership with HDC agreed Negotation with MOH PWC on Implementation of codesign and June 2018 early testing issues across key government organisations that has begun ensures engagement with and from and in process funding for codesign of electronic rewrite health passport produces direction for including Community and Public Health Services that the commonalities and primary care, Early meetings with MOH have passport national process. Proposed to Partner Work with local communities a shared social investment partnership arrangement in occured and funding of $52,000 cost of passport redesign and approach lead to improved place with MoH and HDC, has been allocated to a process electronic implementation access to health and social HSQC with PWC cost to be addressed services and therefore Meetings with Minister Wagner December to February 2018 improved health outcomes. have produced national support (MOH HSC SIP) 1.1 Practice positive partnerships to enhance On track People and their families Consumer engagement, Sub regional group is Restructure of MH leadership group Establish CHC and MH leadership community led proposal for collaboration and co-design are respected as experts in citizen engagement, developing annual work plan for aligns with disability strategy and group community led local networks their own health care and coproduction on projects calendar year 2018 integrated Mental Health Strategy Planning begins for sub regional and sub regional structure to proactively engaged at and design. Joint initiative with proposed CHC proposal to Board. On target for forum target September 18. SIP MH December. different levels in advising CHC and mental health embedded engagement strategy in all Engagement with Maori and Pacific Estblishment and and co-design of new and leadership group local areas disability community leadership in agreeement three DHBs existing health services and early stages march 2018 1.2 systems. Uphold the key principles of the Treaty of On track Whāia Te Ao Mārama Whāia Te Ao Mārama Maori rep of SRDAG on Te Ao Early planning for Maori lead sub Meeting with Maori facilitator and Intersectoral forum: Building Waitangi guiding principles guiding principles Marama strategy panel. regional planning identified Maori with disabilities reslience and welleing embedded in all actions embedded in all actions Disability plan and monitoring committed to engagment and through person/whanau lead to improved lead to improved established to embed and development hui community activated engagement with Māori engagement with Māori develop critical Maori lense innovation. September 18 1.3 with Disabilities. with Disabilities. consistently. Utilize the skills and resource of the Disability On track On hold On track Disability action grioups Disability action group to be Champion networks refreshed in Disability Action Group based on DAG model and TOR agreed Wairarapa DAG activated Action Group and refresh the Champions network and associated champions established at Hutt and all three DHBs. Website CCDHB model in development with Wairarapa DHB ELT November 17 March 18. Policy to ensure efficient action within the DHB provide easy navigation Wairarapa DHBs 17/18 development to socialise now Wairarapa DHB ELT to support and first meeting March 18. Hutt development begins. Hutt networks and support for planned champions and advisor resource. model to be developed beginning Valley DHB development people using services sub March begins March 18 1.4 regionally Ensure better accountability by creating a Complete On hold On track Accountability for Monitoring framework Development of Outcomes Draft framework being codesigned Monitoring framework in place. March 18 Wairarapa icon in monitoring framework improvement of practice is developed and actively framework is a key component of with team. Completion of work plan for place. Dashboard measurable and leads to utilised. Dashboard of the strategic plan and launched establishment of alert/icon at development Hutt Valley initiatives reduced baseline structural June 2017. Academic and Wairarapa DHB. Establishment of begins by June. Analysis of admissions to hospital, measures is adapted for analyst input to review quality webpas Wairarapa DHB. Target CCDHB ALOS internal shorter stays where Hutt Valley DHB followed and implications of disability internal medicine CCDHB for medicine quarter 4 (Annual admission is necessary and by Wairarapa DHB 18/19 alerts analysis of longer average length of Plan) by increased quality stay feedback from people using community and hospital 1.5 services. Lead a disability responsiveness education On track Consumer led education Learning plan on track and KPIs for each local area Consistent learning framework shared Resource commissioned (disability Consistent framework for programme throughout the 3 DHBs targeted to for clinical and implemented in each local educator in place sub regional educational tools and led) to produce data on sub on learning sub regionally with non-clinical staff DHB.Education of staff co sub regional consistency of aims and optimal staff outcomes and learning specifc local variations with contributes to greater led with education team outcomes has been framed models annual targets understanding by staff and people with lived leading to improved patient experience including experience and a seamless whanau. (70%) to date. patient journey. 1.6 Inclusion & support CCDHB HVDHB WDHB 3 DHB Improve access to funding, information, services Behind The guide to Under 65 Guide will be completed Guide has been edited Three DHB DSS NASCS checking MOH approval sought Guide completed and and support schedule NASCS (DSS) services within 17/18 annual plan Consultation process with MOH details and completing approval launched June 2018 means people will timeframe completed process awaiting appointment understand what they can access and where. This enables people and their families to be more in 2.1 control of their support. Ensure IT platforms accommodate disability On track Technology used across New health passport will be Consultation and negotiation with Co design with Price Waterhouse Proposition will be with all parties Sub regional launch for responsiveness tools health and disability tested sub regionally and MOH and HDC completed for MOH DHBs and HDC phase one and for prototype testing testing application over three services enables health national roll out considered first stage funding two completed 27 October months 18/19 practitioners to understand the various components and inputs to the overall support of people and their 2.2 families.

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quarterly Project Reporting Status Measures Measures 2017 - 2018 Recent Work Completed Current Activity Major activities planned next Target date and expected quarter outcome/any risks or issues Improve transition for children and young people Not due to On track Not due to The electronic pathway and An electronic version of the Apropriate skills to develop Contract to develop electronic version Testing with families feedback on Prototype approved and from child to adult services within the healthcare start start tool kit co-designed with tool kit is launched in electronic version with being negotiated and aligned to health prototype of application testing with Primary care system families enable them to preparation for primary demonstration site families passport development planned 18/19. Prototype access community health care demonstration Hutt identified agreed by February 2018 and disability services with Valley Three DHB general practice as allies. 2.3 Ensure health professionals are flexible and cater On track Tools such as the disability Disability alerts quality Data entry process and Patient pathways and clinical Stocktake of clinical service use of Alerts pathway and 18/19 to a persons specific needs alerts, the health passport framework and process is framework simplified CCDHB engagement plan developed for each alerts plan in place for incremental and shared care planning finalized Three DHBs. and Hutt Valleynand project plan local dhb. Preparation for quality improvement enable staff to facilitate a Dashboard for CCDHB is refreshed clinical/patient collaboration on alerts seamless journey through agreed (CCDHB ony) Wairarapa DHB health services, including funded health and disability services 2.4 Encourage better use of technology On track IT tools give people options see above 1.1, 2.2 and 2.3 Maurice Priestley beginning contract Launch of website March 2018 on ensuring critical on website FAQ for people with information about access needs individuals can be shared. An electronic version of the health passport enables disabled people who prefer to use their devices enables to share support information in real time. 2.5 Improve accountability and integration across the On track A disability clause obligates The new sub regional plan New clause circulated with Examples and discussions held with Reminders for reporting sent out Summary report on planning and funding arms of the DHB providers to develop plans provides opportunities for launch of updated strategy providers as to what they can and advice hotline in place implementation across NGOS and improve access on a refreshed approaches complete during 17/18 and Primary care will provide developmental basis each across all services to baseline for future action year. This improves access include disability to general health and community services. 2.6 Ensure people are supported in decision making On track Staffs understand Informed consent Negotiated resource to develop Consultation begins with community Draft kit completed for wider Kit will be released June 18 supported decision-making guidelines for staff, people key annual plan deliverable and staff champions consultation as per annual plan enabling people to better with learning disabilities will participate in decision- be completed 17/18 making about their health (contribution to longer term care. skills development and supported decision making) 2.7 Promote a whole of life approach to needs On track A whole of life approach Concept for a new model Project plan and strategic whole Analytics work stream will report key Concept will be developed in more Model for procurement of assessment and service coordination across needs assessment proposed to ELT CCDHB of life leadership group population and impacts of current detail based on analytics and ICT simplified approach services reduces established model of needs assessment feedback presented June 18 fragmentation and enables more timely access to the appropriate support pathways irrespective of age group and condition. 2.8 Access CCDHB HVDHB WDHB 3 DHB Create an enabling environment where the On track Identification of targets for Negotiation of a Frequently Review of unfinished work on Complete Q and A website CCDHB CCDHB model used to adapt person is at the centre Information available in 18/19 by each local DHB asked questions website and navigation of services by internet for Wai and Hutt 18/19 plan plain language documents with its Disability Action suitable skills set identified and in accessible formats Group (CCDHB first) across the 3 DHBs electronically and in hard copy puts the person in charge of their journey through the health system. 3.1

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quarterly Project Reporting Status Measures Measures 2017 - 2018 Recent Work Completed Current Activity Major activities planned next Target date and expected quarter outcome/any risks or issues Community Resilience is promoted across the On track On track Not due to Collaboration with councils, Vulnerable persons plan in Good neighbours network Vulnerable persons plan drafted Interagency collaboration and Draft plan is approved at sub-region start other government bodies place for all DHBs. A (WCC) information shared sub Training on community circles for staff consultation. Review of contracts CCDHB. Small and community members community circles concept regionally and consumers being made available to ensure emergency preparedness demonstration site for working across localities for building community is considered. Plan for community circles is provides safety and better reslilience is developed for commissioning community circles in considered algned with whole emergency preparedness consideration fo at least one DHB of life nasc where there is a as well improved commissioning high percentage of isloated connection with neighbours older people and other natural supports. 3.2 Physical access remains a priority within the DHB On track On track Not due to As buildings are developed, 17/18 design of new Concept for children’s hospital Engagement plan is implemented Service design is rigorously February 2018 phase one start input from access experts buildings has Barrier Free has detailed access and developed alongside communities ensures that future health and consumer inputs at an consumer engagement plan. most impacted care is fit for all groups early stage Early engagment on Mental irrespective of impairment. health Unit planned 3.3 Improve access to New Zealand Sign Language On track Each year deaf people Resources electronically MSd funding obtained. NZSL Co design of resources for staff and . Publication of research leads to Phase one of implementation interpreters and quality of care for Deaf using general and mental available for improved project lead employed for sub Deaf consumers being undertaken. wider national communications on of full accessibility plan for community health services have a navigation of health regional programme. Research Conference presentations on Deaf deaf issuesIntranet and internet NZSL users will be completed safer journey through the services by deaf people. publication accepted by NZMJ issues Auckland and Otago Nov 2017. resources launched. New funding June 18. New funding health system, have Guidelines for working with to be sought via MSD and MOH identified for phase 2 improved health literacy people who are deaf and and a large proportion of hearing impaired approved. staff understand the cultural needs of deaf 3.4 people. Health CCDHB HVDHB WDHB 3 DHB 4.1 Direct a culture shift towards person/whanau- On track On track Not due to Disabled people are able to Evidence: Processes for Project plan for whole of life Analytics work stream gathers data on Concept for whole of life pathways Concept for whole of life nasc directed care Project plan for whole of life needs start access quality health care managing system & funder assessment. Interim clinical people impacts on people across all developed based on data is completed and assessment in community and hospital complexity impacting governanc established CCDHB funders. Thematic analysis on issues gathering.Education on funding procurement is planned irrespective of multiple individuals facilitate & Hutt. Interim clinical facing people with multiple inputs streams and discharge processes Interim clinical governance established CCDHB specialists and conditions. collaboation & Improved governance established CCDHB indicates need for consistent are co designed. and Hutt and Hutt discharge processes in hospital services Support PHOs to improve access to services by On track Alliance Leadership Teams Hutt Valley collaboration Strategy socialised with alliance Each PhO and local area engaged in PHOs report specific actions education information from and by empowered and PHOs lead the way in agreed on demonstration teams and specific local planning first steps of each individual and subsequent plan in 17/18 consumers improving disability site. CCDHB and deliverables agreed plan end of year report responsiveness in general Wairarapa Compass Liaison and support from SIP on practice settings by Endorse and co produce E plan with each PHO and reporting integrating a professional health passport and whole for quarter 4 and consumer disability of life pathway. lens in education. Education plan in place with clinical staff. 4.2 Support any initiatives developed in the area of On track On track Not due to Rehabilitation services Collaboration SIP SPO research into rehabilitation Meetings with Duncan Foundation and Third meeting with Duncan A plan for first clinics and improving access to rehabilitation by providing start improve with disability and MOH with a new NGO beds undertaken 2014 is subregional allied health supportive of Foundation lead and consultation future potential for wider advice and expertise available to the Directorate community input and good alliance with philanthropic revisited. SIP negotiation with new initiative with SRDAG and other interested community hub approach to practice models are shared funding initially targetting ABI leads to identifiction of bodies rehabilitation (wider sector) across health ACC and the post polio survivors is possible skill sharing 18/19. Update June 18 Ministry of Health. supported and first clinics based at NZAL centre 18/19 4.3 Provide staff with engaging education and On track Staff at pre-registration and Disabilty literacy guide to e learning launched at Hutt and Wairarapa proposal to ELT for Joint meeting with Educators from Disability literacy guide is information to ensure better health outcomes for post-registration are be completed and made CCDHB. E learning mandatory mandatory E learning all staff each area and disability strategy socialised and well identified people within the hospital system competent in disability available electronically and and launch date set Wairarapa endorsed. New e learning model for team agrees a sub regional by critical front line staff in literacy and adapt care to in hard copy for targeted to Wairarapa DHB signed off linked with disability literacy guide for each each local dhb meet the needs of any front line administration disability alert proposal. intranet locally person irrespective of staff 4.4 impairments or health.

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